Jungle Yellow Fever, Rio de Janeiro.

To the Editor: Yellow fever control in Brazil through vaccination campaigns began in 1937. However, cases of jungle yellow fever still occur despite the existence of a potent vaccine and immunization campaigns focused on areas endemic for the jungle form of the disease (1). Most of these cases are in men in rural areas.

In Brazil from 1980 to 1998, 376 cases of jungle yellow fever were laboratory confirmed (by virus isolation, with or without immunoglobulin [Ig]M-capture enzyme-linked immunosorbent assay [MAC-ELISA] and immunoperoxidase stain), with 216 deaths (case-fatality rate 57.4%). Most cases were from Maranhao and Goias States, with 99 and 41 cases, respectively; Goias, in midwestern Brazil, reported a case-fatality rate of 95%.

During 1998 to 1999, 106 cases of jungle yellow fever were confirmed, with 40 deaths (37.7%). During 1999, 75 cases were confirmed, compared with 34 cases in 1998 and a mean of 20 cases per year from 1980 to 1998 (2). In 2000, 84 cases were confirmed, with 40 deaths (47.6% case-fatality rate). During 2000, the probable site of infection for nearly all cases was in Goias, with 53 confirmed cases and 23 deaths, suggesting epizootic circulation of the virus (2). These cases were in unvaccinated persons who became ill in their home states after traveling to endemic areas for tourism or work.

In Brazil, almost two thirds of the territory is considered an enzootic area (3). Rio de Janeiro State is not endemic for jungle yellow fever, but in January 2000, the Oswaldo Cruz Institute confirmed a case of yellow fever in a 24-year-old woman who had traveled to a national park in Goias State on December 28, 1999, with a group of 17 persons. Yellow fever infections were also confirmed in tourists from other states who visited this park in late 1999.

The young woman became ill on January 3 with fever, headache, retroocular pain, prostration, anorexia, and nausea. She returned to Rio de Janeiro on January 5 and visited a private clinic on January 7, when a complete blood count, platelet count, urea, creatinine, liver function tests, and dengue serologic testing were performed. The patient had leukopenia (1,730 leukocytes/[mm.sup.3]), 100,000 platelets/ [mm.sup.3], AST 911 U/L and ALT 680 U/L, creatinine 0.90 mg/ dL, urea 10 mg/dL, and normal bilirubin and protein. Anti-dengue IgM serology was negative. A blood sample was collected January 11 for yellow fever diagnosis. Reverse transcription-polymerase chain reaction (RT-PCR) test was performed on RNA extracted from the serum (4), and virus isolation was attempted on C6/36 cells, both with negative results. A MAC-ELISA test was positive for yellow fever, with a serum IgM titer 1/80,000 8 days after onset of symptoms. The patient recovered within a week. After confirmation of this case in the only person who became ill in the travel group, yellow fever IgM serologic testing was performed on the other group members, all of whom tested negative. RT-PCR and virus isolation were not attempted because the sera were taken after the viremia period.

Control measures for the Aedes aegypti vector were promptly taken for a radius of 300 m around the patient's home. A vaccination campaign was carried out, during which 735 neighbors were vaccinated. An epidemiologic survey was conducted in the area by using active surveillance for all symptomatic cases of fever during the period of yellow fever transmissibility. Blood samples from patients with fever were assessed for yellow fever virus and antibodies. Surveillance was intensified immediately in Rio de Janeiro State, and our laboratory examined 54 sera from patients who had traveled recently to endemic areas and who had compatible signs and symptoms (in accordance with a nationwide protocol). All these persons tested negative for yellow fever.

From January to July 2000, [is greater than] 16.9 million people were vaccinated against yellow fever (2); however, cases continue to occur. Unvaccinated persons who visit yellow fever-endemic areas pose a high risk of introducing jungle yellow fever cases into nonendemic areas.

References

(1.) Barros MLB, Boecken G. Jungle yellow fever in central Amazon. Lancet 1996;348:969.

(2.) Ministry of Health. Notified cases of yellow fever by state, Brazil. Brasilia: National Epidemiology Center; 2000.

(3.) Vasconcelos PFC, Rodrigues SG, Degalier N, Moraes MAP, Rosa JFST, Rosa EST, et al. An epidemic of sylvatic yellow fever in the Southeast Region of Maranhao State, Brazil, 1993-1994: epidemiological and entomological findings. Am J Trop Med Hyg 1997;57:132-7.

(4.) Deubel V, Huerre M, Cathomas G, Drouet M-T, Wuscher N, Le Guenno B, et al. Molecular detection and characterization of yellow fever in blood and liver specimens of a non-vaccinated fatal human case. J Med Virol 1997;53:212-7.

Ana M.B. Filippis,(*) Hermann G. Schatzmayr, (*) Cecilia Nicolai,([dagger]) Mary Baran,([dagger]) Marize P. Miagostovich,(*) Patricia C. Sequeira, (*) and Rita M.R. Nogueira(*)

(*) Oswaldo Cruz Institute, Oswaldo Cruz Foundation-FIOCRUZ, Rio de Janeiro, Brazil; and ([dagger]) Municipal Health Department, Rio de Janeiro, Brazil