Yellow Fever Lecture Ktes Harvard, 1963 -- ------ _______ ;_ Evolution of public Health Administration v&&hods for Braventlon of Yellow Fever See what is Yellow Fever? Before 1900 - (1) Quarantine (2) Firing Cannon (3) Flight (4) Vaccine Sanarelli (1897) Bacillus Icteroides (Wasdin and Gettings BBS confirmed 1839) (4) Anti Amargl Serum (Monte. 1900) (6) Havana - 1900 - Thorough cleaning of city - Havana - 1901 (a) Attack on breeding places of all mosquitoes attack on infected adults. (b) Fumigation (s) of infected houses and (c) isolation and screening of cases. Gorgas surprised at success-credited victory to fumigation Evolution of Public Health Methods in Prevention of Yellow Fever (1) What 3s Yellow Fever? causation vector animal host clinicel pathology immunology epidemiology wave-like phenomenon like measles But some endemic areas some enzootjc areas distrSb&ion Havana 1901 double victory Yellow fever and malaria (firsts) Gorgas 1902:'; look foreward in the future to a time when yellow fever will have disappeared entirely as a disease of mankindL" Panama - repeated !Fumigation (8) All houses Panama failed,Gorgas concentrated on anti-larval work for yellow fever L Separated yellow fever from malaria Anophelines natural foci v - artificial foci - artefacts never on ground - never in forests in Americas - Attack on u 0s a WV ' breeding very expensive - weekly inspection of every building, house, yard, compound, and boat Panama success; 0. Cruz - Rio de Janeiro Liceaga Joe White Overall Observation (a) Reduction (not eradication) of v in large endemic centers led to (i) Disappearance of yellow fever from endemic centers - rapid. (Ii) disappearance of yellow fever from all of tributary areas - more slowly - (x) epidemiology of control confirmed &-ies aegygf;b as only vector, man es only victim (b) Endemic centers were few and could be known by rapid surveys and consul- tation with local physicians 1999 Gorgas reiterated belief in eradicability of yellow fever Definition of eradfcation 1913-I4 Rose to Asia Iby loI5 yellow p .evor commlrss$onIW C GorgEsJComitted to eradication of Y.F. 1916 swvoy Eduador Peru Colombis Venezuela and coast of Brazil - Only endemic center was Guayaqull Nogn 'ii introdirced vaccine Program - Ecuador Peru Guatemala (Brazil) Honduras, ElSalvador Nicaragua and iflexico - Bacaramanga Colombia - 8 countries succeeded - Brazil Brazil - 1923 Endemic centers - capital cities North Brazil - Weekly visits each house Pouring out water, removing trash, destroying containers, puncturing roof gutters, fishing water jars and cisterns. Rockefeller Foundation repeated experience of Corn. F. A. 1919-1922 1925 victory in sight - African -.S$udy beauno 1426 Revolution 1924 Virus to monkeys 19yf?28 Victory in sight Lengthened cycle and attempt at v eradication Rjo outbreak 1928 Widespread dessem:nation 3 gears to dominate As we look back - first decade of Rockefeller Foundation work, including Noguchi's results were a failure - 1928-29 Public Health Administration in Rio turned the page back to 1901 - put faith in fumigation (flJt rather than (a)) Lost, almost a year - Hindle and Aragao Vaccine 1930 - Rockefeller Foundation accepted yellow fever as major commitment in Brazil - FLS in direct charge Obvious that m EgressZon curve flattened (lengthened cycle gave yellow fever in Recife 0.8 actually 26$) Obvious that yellow fever regression to zero was only apparent. FLS Learn to think liite Mata mosquito DecS.ded to make v, reports, the end product of yellow fever ex- penditures as certifiable as the bank account. New low level approach ties aggy&j. house capture yellow fever viserotomy Aadesaeesnti eradication 1933 but viscerotomy already 1931 - endemic yellow fever and jungle yellow fever Endemic yellow fever liquidated 1934 Jungle yellow fever 1932 - 1933 Then 1934 to 1940 Wave;'r/accine 17 D 1936 Fch vaccine - Besis of choice Mass vaccination Small Pox Eradication of &des aem - Spread of USA, etc. Introduction of DDT Local Resistance DDT -2 Yaws Small Pox Malaria Yellow Fever Lecture Notes - Harvard 2962 .."-.. "------. .-- Yellow Fever and Eradication concept Bfg news in Yellow Fever D.S. joins up in war against 3 questtons !&at is Aedem? F+adicstion? Ye1 low Fever? 1. what is S? 3 slides - urban vector of yellow fever and ather vi.ruses 2. Vhat is eradication? Eradication is the most important justification of International health - Evolution from notification and quarantine to Eradication and ssaking out se&beds of Infection, Yellow fever aided in discrediting Eradication; contributed greatly to Rehabilitation. What is FXadication? Definition Ex radix Eradication an absolute Does not recur in absence of preventive measures unless reintroduced: Local state national regional global Eradicate Error Eradicate hunger Congenital syphj.lis What fs Yellow Fever? Yellow Fever - as human disease Onset - fever headache body pains - active congestion nausea - anxiety Fever and pulse disproportional 24 hour lull after 48 to 72 hours fever, albuminuria - passive congestion, hemorrhage icterus, anuria death - 4 to 7 days (Range 3 to 10) Mortality 50 to 60% of clsssical cases 5 to lo % - mild cases - Real mortality based on infection Picture of Severe infection followed by severe intoxication Symptoms per se not diagnostic Course and timing important. Death or complete recovery - 2 slides pathology 2 Permanent immunity - no second attack Epidemiological Dpta: Short incubation period Short period infectivity no carrier state No chronic cases Vector wi - external incubation 9 to 12 days (Davis 4 days) Infected for life - no transovarian infection - Effective infection 6 weeks Etiology Small virus - not known to exist in nature except in unbroken chain of acute vertebrate infections (Primates andmersurials) caused by bite of previously infected mosquito vector. First aebovirua - more intensive study than any other virus \ Monkeys Marsupials best prototype Chick Embryos - Very young chicks Mouse brain - tissue culture Viscerotropic > Viscera - Neurotropic > C.N. '- Yellow fever encephalitis may be fatal. Different incubation periods Virua variable in cultures 17 D vaccine mutant (Non-reproducible) All strains homologous1 Neutralization Test - in practice very reliable in spite of B. virus group overlap. Distribution of endemic yellow fever Before 1900 American 1900 to 1931 Slide America Africa 1900 to 1931 Slide ACrica Yellow fever as a Zoonosis Jungle Yellow Fever Primary in primates of forest - Marsupials - Man accidental infection - no different from &des m yellow fever Hosts All primates apparently hosts When infected Susceptibility series but susceptibility not correlated with enzootic efficiency - Americas - cePus - spider Some susceptible howler - rzarmosets Africa - Bush babies monkeys Hone susceptible Asia - Rhesus and Cynomologus All SUsceptible Vectors (Eaemogogus spegaazini 3 slides 3 ( Americas ( equinus mesodentutus ( Aedes welen= ( Sabethes chloropterus Africa mfricu kdes s- As?a Aedes albopictus Enzoot,d_c and ) Same factors of relationship virus vector non-imnune host Epir0o#tic 1 es govern endemic and epidemic mes aem human yellow fever, Yellow fever distribution after 1932 Americas slide Africa slide Yellow fever and eradication Eradication concept after Pasteur Yellow Fever before 1900 - no cure, no prevention, safety in flight Mississippi Valley 1878 US Yellow Fever Commission 1879 Carlos Finlay 1881 Reed et al 1900 Gorgas Havana 1901 US Army Commission Key Center Eradication - s Reduction in large cities only Gorga s 1909 Rockefeller Foundation chartered 1913 Threat of Panama Canal Rcckefeller Foundation Yellow Fever Eradication 1915 - l925 success 1925 Alrican Adventure 1928 Pub - Virus to Asian Monkeys Transmission Non-s But 1926 - military epidemic - surprise - led to attempt to eradication v Parahyba 1928 - Rio de Janeiro 1929 - Socorro and Guasapati Yellow Fever 1928 - 1931 Slide Recife 1729 - Not able to withstand Bombardment with virus Situation Brazil end of 1?29 Yellow fever program had failed! Eradication concept discredited w - 1930 missed Why cause (1) Inadequate attack on ;;edes? (2) Unknown mechanism of survival? Both v and yellow fever virus survived below threshold of visibilityl Reorganization: FLS personally responsible - From the top FLS 3 months - maps, itinerary, routine oiling foci. Learn to think like inspector SFA 52 - Explosion in Nichteroy Search for low level incidence - lowering thresholds of visibility - (a) Viscerotomy for yellow fever (b) Adult captures for v Results showed (a) Inadequate attack on m sea; but because of limited area of attack on v* not in Key Centers With lowered thresholds Visibility (a> 1731 - Endemic silent yellow fever NE BR. Key center method not applicable (b) 1932 - yell ow fever without Aedes aepva - Key Center method not applicable 1933 Jungle yellow fever Brazil, Bol., Colombia, Venezuela (c) 1933 - as sea disappears port cJtl:.es Importance over shadowed by jungle yellow fever, etc. Rockefeller Foundation Yellow Fever eradication then had failed because of 2 unkrmwn mechanisms of surv i.vail Silent endemic yellow fever e" Laminated by village and rural snti-Aedss am mea a'd.rea - the end of Awm yell.ow fever August 1934 b*ut not wadfated. Roots of yellow fever infection in forests - 1.933 How important is jungle yellow fever? What measures should be taken? In spite of previous non-recognition jungle yellow fever important in its own right - young mans 3?sease the engaged young matis disease 1932 - Sta Crua de la Sierra - v (Attacks both sexes and all ages among Indians $n forest House and Work / Forest. Attacks mostly adult men - lumber and chic&ros and materos 1934 - 1940 Cel. Ponce 7 slides 1935 - Teofile Qtoni 1936 - Figueira - Cambara 1938 - Infectious cases Rio Retrospective - Rio 1928 - Socorro, Guasapati 1929. Slide endemic area and towns Not only was jungle yellow fever a threat to cities and towns but was important for rural populations - no cure, no prevention - stay out of 3nfected forest and starve. - Esti.mated 15000 cases Brazil 19381 Measures taken (a) v eradication for ci.ties as permanent protection of entire urban populations (b) Vaccination for individual protection - Rural populations Vaccination First Finlay believed he was giving mild infections ! (Protected'did not protect; ' infected)' Killed virus vaccine Rio - 1929 Iater animal tests serum virus 1931 modjfied viruses tissue culture and serum - Heterologous Sera Fch neurotropic - Svarification - Failed in Brazil 17-B 1936 - 1937 '5 slides Use in field 1937 - 1942 Reduced antigenicity Serum Hepatitis Postvac Encephalitis Post-Vat Encephalitis w-lth Fch Neurotropic vaccine Costa Rica 1951 Nigeria 1952 Choice of vaccines Vaccination Americas - Rural areas - Travelers Africa - Urban and rural s Eradication Second E adication not planned Slide Careful administration Complete coverage Oiling of focf. Adult captures for missed mother foci Eradication discredited 1929;recommendation to decentralize ,to local health units. 1934 proposal to eradicate in Brazil aaePv&J not yellow fever, focus of attack. Cities h&d on monthly cycle - 3/4 men for suburbs. Peripheral expansion from each eradicated center (Soper's Law) Interior towns, villages, rural areas - Cities of South Brazil, f_ncluding Sao Paula, where yellowfever never occurred. Paraguay Bolivia, Peru, Colombia, Venezuela, Cuba USA 1939 - Sfx states and Rio de Janeiro 1941 - Brazilian objective eradication! PABO 1942 - Bolivian resolution 1946 - Reinfestation Brazil PAHC 1947 - PAHO resolution Braejl Fjrst official international eradication program Brazil carried early load Soper's Law of Peripheral Expansion of eradication effective internationally as well as internally. Yellow Fever Helps - Cistribution 1946 - 1953 1 slide k?J Panama Gxico 1948-58 2 slide I(751 (15) St.0 Domingo de lo8 Colorado 5 s1.1de.s dc> Trinidarl Caracas 1.954 - 3 slides Trinidad an3 Caracas first reports since 1911; Long apparent absence t1o index of safety Id{ j to 8 countries each yr. 4 slides e Since eradicatfon 1947 resolution all countries on the mafnland except Canada, USA, El Salvador, Chile Uruguay DDT eases loedjresistancs of qLedes em Scper's Law - Against USA 1954 - even though not of primary concern - Slide 19% Aedes situation. 1958 -'Brazil 1942 1959-1950 - &xico Mexico 1961 five year limit 1962 US joins up. US decision - not based on increased threat Yellow Fever, Dengue, encephalitis and other viruses; but based on recognition of right of other nations which have eradicated u to be protected against reinfestatfon from our cities and ports. New principle in International Health practicebUS joined in 5 year vote in 1962 against 2 laggard American nations in Sma 1 1 Pox eradication. By-products of m eradication An+&e$e~&~i.,$kasil 1939140 - missed in 1930-31 Rehabilitation of eradicotfon concept 1947 US National Malaria Eradication Program 1950 PAHO Kalaria, Yews, Small. Pox hter `WHO Malaria, Yars Small Pox 1955 APHA endorsed eradication concept USA - Poliomyelitis, Liohtheria, Tetanus, Whooping Cough (As Public Health problems! But experic:.;ce will teach.) Tuberculosis Syphilis We learned from v and yellow fever (a) To lower threshold of visibility (b) to refine methods as zero is approached (c) the need for careful administration, meticulous checking, based on detailed records and complete coverage (d) the growth power of eradication through peripheral expansion. Eradication is an increasingly useful concept as world shrinks and as Pan Am and World Health Organizations become more adept at coordinating preventive programs in all the countries of a region. Just as part of a coluntry cannot enjoy t'ne benefits of oradfcatioc apart from other units, so no $2ogle country may safely relax to enjoy its own eradication efforts, so lung as eradication has not betin -extended to those countries from which reinfection or reinfestatjon may come. Yellow Fever in Africa vs Yellow Fever in AmerJ.cs 5 cycle sl4.des Aedes in Americas domestlc Africa domestic and forest - Prospect for eradicationof m (Stegomyia) WzQ Human to Human Vector in;trtllages close to forest Africa no m outbreaks in seutra1 and Eastern Africajno virus to Azfa. FLY visit to S&an 1936 Large outbreak in Sudan Slide, Afr",ca er,dcmlc 194C- Ethiopia - 1959-60-61 62 - Slmpsoni.? Still unknowns inyellow fever Threat to Asia - greatly reduced in absence cf v in proxim-lty to Infected forests. (No urban yellow fever in central and Eastern Africa) Monkeys succeptible - vectors available Eradication of Aedes m Jn Asia Final slide. - he-rro~r-l;sdjc;isease jr. 1&>?1 la and Bangkok. -