Review
The revised global yellow fever risk map and recommendations
Lancet Infect Dis 2011;
11: 62232
*Members listed at end of paper
Epidemic Intelligence Service
(E S Jentes PhD) and Division of
Global Migration and
Quarantine
(E S Jentes, M D Gershman MD),
Centers for Disease Control and
Prevention, Atlanta, GA, USA;
International Health
Regulations (G Poumerol MD),
Public Health Information and
GIS (J Lemarchand MS), and
Yellow Fever Initiative, Global
Alert and Response
Department (R F Lewis MDCM),
WHO, Geneva, Switzerland;
National Travel Health
Network and Centre, UCLH
NHS Foundation Trust, and
London School of Hygiene and
Tropical Medicine, London, UK
(D R Hill MD); Division of
Vector-Borne Diseases, Centers
for Disease Control and
Prevention, Fort Collins, CO,
USA (J E Staples MD);
Department of Biological
Sciences, Redeemers
University, Ikeja, Lagos State,
Nigeria (O Tomori DVM);
Travellers Screening and
Vaccination Clinic, National
University Hospital, Singapore,
and Institute of Public Health,
Heidelberg University,
Heidelberg, Germany
(A Wilder-Smith MD); and
Pandemic and Biodefense
Fund, Kleiner Perkins Caueld
and Byers, CA, USA
(T P Monath MD)
Correspondence to:
Dr Emily S Jentes, Division of
Global Migration and
Quarantine, Centers for Disease
Control and Prevention,
1600 Clifton Road, MS E-03,
Atlanta, GA 30333, USA
ejentes@cdc.gov
622
for vaccination, 2010: consensus of the Informal WHO Working
Group on Geographic Risk for Yellow Fever
Emily S Jentes, Gilles Poumerol, Mark D Gershman, David R Hill, Johan Lemarchand, Rosamund F Lewis, J Erin Staples, Oyewale Tomori,
Annelies Wilder-Smith, Thomas P Monath, for the Informal WHO Working Group on Geographic Risk for Yellow Fever*
The changing epidemiology of yellow fever and continued reports of rare but serious adverse events associated with
yellow fever vaccine have drawn attention to the need to revisit criteria for the designation of areas with risk for yellow
fever virus activity, and to revise the vaccine recommendations for international travel. WHO convened a working
group of international experts to review factors important for the transmission of yellow fever virus and country-
specic yellow fever information, to establish criteria for additions to or removal from the list of countries with risk
for yellow fever virus transmission, to update yellow fever risk maps, and to revise the recommendations for
vaccination for international travel. This report details the recommendations made by the working group about
criteria for the designation of risk and specic changes to the classication of areas with risk for transmission of
yellow fever virus.
Introduction a travellers ocial documentation; it becomes valid
Yellow fever is an acute infectious disease caused by the 10 days after vaccination and remains so for 10 years.6
yellow fever virus, a avivirus transmitted in tropical or Yellow fever vaccine is given for two reasons: to protect
subtropical areas, mainly through the bite of infected travellers visiting areas with risk of yellow fever virus
Aedes spp mosquitoes in Africa or Haemagogus spp transmission and to prevent international spread by
mosquitoes in South America. On both continents, both minimising the risk of importation and translocation of
jungle (sylvatic) and urban transmission cycles exist. In the virus by viraemic travellers.
the jungle cycle, the virus is transmitted between non- Every year, about 9 million people from Asia, Europe,
human primates and various mosquito species in the and North America travel to countries where yellow fever
forest canopy. In the urban cycle, the virus is transmitted is endemic;7 the number of travellers who actually visit
between human beings and mosquitoes (predominately areas within these countries where transmission of the
Aedes aegypti) in urban areas. In Africa, transmission of virus occurs might exceed 3 million.8 Unvaccinated
the virus can also occur in an intermediate cycle between travellers who visit areas in Africa during periods of
human beings or non-human primates and Aedes spp epidemic activity have an estimated risk of illness of one
mosquitoes that breed in tree holes in savannah areas. in 267 and risk of death of one in 1333, although the risks
During the past decade, ocial reports of yellow fever are likely to be lower during interepidemic periods.8 Risk
incidence (50120 cases a year from South America and of illness and death for individuals travelling to South
2001200 cases a year from Africa1) probably under- America might be about ten times lower than it is for
estimate the true number of cases. Many cases of jaundice those travelling to Africa, because the rate of transmission
and fever (a surveillance denition of yellow fever) are in the jungle cycle is lower there.8 However, the risk of
not assessed, unexplained deaths go unreported, yellow fever for travellers visiting any area depends on
symptoms suggest alternative diagnoses, and, in some the time of year, the travellers itinerary and activities,
countries, surveillance systems for yellow fever are not in vector population densities, and the presence of
place. The case-fatality rate ranges from 20% to 50% and circulating yellow fever virus. In endemic areas with high
is partly dependent on case recognition and testing vaccination coverage, the occurrence of yellow fever
practices.2,3 Because no antiviral treatment exists for the outbreaks has decreased substantially.8 Yellow fever
disease, prevention through use of personal protection surveillance in human beings in these areas does not
measures and vaccination is crucial to lower disease risk accurately show the underlying risk for exposure,
and mortality. especially for non-immune travellers, because the jungle
Yellow fever 17D (YF 17D) is a live, attenuated vaccine cycle of the virus in non-human primates is not aected
that has been in use for more than 70 years, with by widespread human vaccination. This hidden risk for
hundreds of millions of doses given during this period.3 virus exposure presents a challenge for health-care
Although immunity from vaccination probably lasts for a providers about whether to vaccinate patients preparing
lifetime,4,5 a 10 year interval between vaccinations is for travel.
stipulated in the International Health Regulations Countries where the vectors and non-human primate
(2005)3,6 for individuals travelling to countries with a hosts exist are vulnerable to the introduction of yellow
yellow fever vaccination entry requirement. The fever virus, even if the disease is not endemic. Importation
International Certicate of Vaccination or Prophylaxis is of the virus by an infected traveller could initiate an
www.thelancet.com/infection Vol 11 August 2011
 Review

Classication criteria Risk for Vaccination

infection
Endemic Areas with persistence of enzootic yellow fever virus transmission for long periods of time, where yellow fever High Vaccination recommended for all travellers aged
vectors and non-human primate hosts are present, and where yellow fever infections are repeatedly reported 9 months or older
in human beings, non-human primates, or both, where yellow fever cases in human beings were reported
regularly before high yellow fever immunisation coverage was achieved, or where serosurveys (prevaccination
era) show evidence of high levels of yellow fever virus infection
Transitional Areas bordering zones that are endemic for yellow fever with periodic evidence of virus transmission during Moderate Vaccination recommended for all travellers aged
epizootic or epidemic expansions, where yellow fever vectors and non-human primate hosts are present, and to high 9 months or older
where yellow fever infections are reported in human beings, non-human primate hosts, or both (sporadic or
epidemic) at long intervals and during yellow fever epizootic cases or epidemic expansions from bordering
endemic areas, or where serosurveys (pre-vaccination era) show evidence of yellow fever virus infection in
individuals born before the previous yellow fever virus expansion
Low Areas bordering zones where yellow fever is endemic or transitional, where yellow fever vectors and Low Vaccination generally not recommended for travellers
potential non-human primate hosts are present, where no yellow fever infections have been reported in either human to areas with low potential for exposure; however,
for exposure beings or non-human primates, and where serological or other evidence of low levels of yellow fever viral vaccination might be considered for a small subset of
transmission in the past might exist travellers whose itineraries would place them at an
increased risk for exposure to yellow fever virus (eg,
prolonged travel, heavy exposure to mosquitoes,
inability to avoid mosquito bites)
No risk Areas where no past or present evidence of virus circulation exists or environmental conditions are not None Vaccination not recommended
conducive to yellow fever virus transmission

Criteria were dened at the 2008 and 2010 WHO consultations on yellow feversome criteria include elements for which there is no scientic basis for denition (eg, high levels, long intervals) and which will
need interpretation by experts with experience in this disease area. Decisions regarding the use of yellow fever vaccine for travellers must consider several factors, such as a patients risk of infection, country entry
requirements, and the potential for serious adverse events after vaccinationin the absence of such information, a conservative approach to vaccination is justied.

Table 1: Classications of geographical areas, according to risk of transmission of yellow fever virus

enzootic transmission cycle, leading to a long-term
infection risk for the local population. This risk is probably
highest in densely populated regions infested with
A aegypti, such as Asia, the Caribbean, Central America,
and coastal South America. The International Health
Regulations state that proof of vaccination might be
required from travellers entering such vulnerable countries
from areas with a risk of yellow fever transmission.6
Historically, YF 17D vaccine has been regarded as one of
the safest vaccines.9 However, yellow fever vaccine-
associated neurological disease (YEL-AND) has been
recognised for many years, and, since 2001, yellow fever
vaccine-associated viscerotropic disease (YEL-AVD) has
been reported.1016 Clinically, YEL-AVD resembles naturally
acquired yellow fever, and, in its most severe form,
presents with jaundice, multiorgan failure, and distributive
shock. YEL-AVD is estimated to occur in 04 per
100 000 doses.17 For people aged 60 years or older, the
reported incidence is roughly four times higher.17 YEL-AND
can develop as meningoencephalitis (direct invasion of
the CNS by the yellow fever vaccine virus) or as
autoimmune manifestations in which antibodies or T cells
produced in response to the vaccine cross-react with
neuronal epitopes and lead to central or peripheral nerve
damage.18,19 YEL-AND is estimated to occur in 08 per
100 000 doses.17 In people aged 60 years or older, YEL-AND
occurs at 18 per 100 000 doses.17 Because of these serious
adverse events, clinicians are advised to vaccinate only
those individuals truly at risk for exposure to yellow fever
virus or who must be vaccinated to meet country entry
requirements. Clinicians should carefully consider the
risks and benets of vaccination for every patient, and in
some cases might choose to issue a letter of medical
exemption from yellow fever vaccination. Contraindications
and precautions to yellow fever vaccination are given in
the WHO website20 and position paper,3 and are presented
in the Advisory Committee on Immunization Practices
recommendations for yellow fever vaccine.18
The global yellow fever risk map
Since the mid-20th century, the global yellow fever risk
map has depicted the best estimate of the distribution of
the virus and has been used to guide vaccination
recommendations for travellers. The rst risk map was
created at the end of World War 2 by the Expert
Commission on Quarantinewhich had been appointed
by the UN Relief and Rehabilitation Administration
and relied on the results of serosurveys and expert
opinion.21,22 In 1948, responsibility for maintenance of
the global yellow fever risk map was assumed by the
Yellow Fever Panel, which had been appointed by the
newly formed WHO. However, the many subsequent
changes made to the map were often done without
documentation of the rationale or methods used.
Historically, the US Centers for Disease Control and
Prevention (CDC) used the WHO risk map in its
publications. However, in 2005, CDC created a map that
diered from the WHO map.23,24 The publication of
dierent versions of the global yellow fever risk map by
public health institutions was problematic for public
health professionals and travel medicine clinicians.
The scarcity of well documented and consistent methods
in yellow fever risk assessment and the changing global
epidemiology of the disease emphasised the need to revise

www.thelancet.com/infection Vol 11 August 2011 623

 Review

Switzerland (the 2008 consultation), after recognition by

Pando
Bolivia
El Beni
La Paz
Cochabamba
Santa Cruz
Oruro
Potos Chuquisaca
Tarija
Elevation and yellow fever
virus transmission risk
<2300 (m): endemic
2300 (m): no risk
Figure 1: Use of elevation to dene yellow fever risk areas in South America
Bolivia is used as an example here, but the same method (specic areas <2300 m in elevation dened as being
endemic for yellow fever) was used for countries situated along the Andes Mountains. Areas 2300 m or above in
elevation were identied with GTOPO30, a global digital elevation model (United States Geological Survey, Reston,
VA, USA).30
and standardise the geographical risk assessment for
yellow fever. For instance, in late 2007 and early 2008, the
disease re-emerged in Paraguay and Argentina after more
than 30 years.25,26 Furthermore, increased numbers of
cases were reported from many countries in central Africa
that had previously reported cases only rarely.27,28 In
addition to vaccine safety concerns and the changing
epidemiology of yellow fever, the International Health
Regulations require WHO to regularly publish a list of
countries and areas with risk for disease transmission.6
WHO updates this list every year in annex 1 of the
International Travel and Health (ITH) publication (widely
referred to as the Green Book).29
The 2008 consultation on yellow fever and
international travel
WHO convened a consultation on yellow fever and
international travel on Sept 45, 2008, in Geneva,
travel medicine experts at WHO and CDC of the need to
harmonise both the classications of geographical risk
for yellow fever and vaccine recommendations. The goals
of the 2008 consultation were to discuss factors important
for transmission of the virus, to establish criteria for the
addition or removal of countries and geographical regions
in annex 1 of the ITH publication, and to revise the yellow
fever risk map and recommendations for vaccination.
The 2008 consultation outlined four levels of yellow
fever risk and classied geographical areas into four
corresponding categories: endemic, transitional, low risk
(changed to low potential for exposure in the second
WHO consultation in 2010), and no risk (table 1). The
factors identied in table 1 were adopted as the criteria
for the addition or removal of countries and geographical
regions in annex 1 of the ITH publication.
After the 2008 consultation, a working group (the
Informal Working Group on Geographic Risk for Yellow
Fever) was formed to systematically assess the risk for
yellow fever virus transmission in South America and
Africa and to ensure that risk maps and vaccination
recommendations were harmonised on the basis of
consistent criteria.
The working group met by teleconference regularly
(roughly every month) from September, 2008, to May,
2010. The yellow fever risk prole (all available studies
and reports) for every country that had risk for yellow
fever virus transmission was systematically reviewed
with the criteria outlined in table 1. In the absence of
specic yellow fever virus data, the working group
members provided expert opinion and used available
data sources on vegetation and elevation of a country or
region to reach a consensus. Whenever possible, the
second administrative level boundaries within countries
were used to describe risk areas. However, subnational
data did not exist for some countries (eg, Rwanda,
Uganda, and Angola). In these cases, decisions were
made on a country-wide basis.
The 2010 consultation on yellow fever and
international travel
In South America, the expert consensus was that areas at
an elevation of 2300 m or higher are not suitable for
yellow fever vectors. Furthermore, no cases of yellow
fever were documented to occur above this elevation.
These areas were identied with a global digital elevation
model (gure 1).
In Africa, the barren or sparsely vegetated lands of the
Sahara desert are not suitable for the development of
immature mosquitoes and were, therefore, not thought
to harbour a risk for virus transmission. By use of the
normalised dierence vegetation index, a conservative
vegetation line was used to separate barren or sparsely
vegetated zones (eg, Sahara desert) from others, including
shrubland zones, which might be conducive to the
development of immature mosquitoes (gure 2).

624 www.thelancet.com/infection Vol 11 August 2011

 Review

Although this line could be readily established west to

east from Mauritania to Eritrea along the southern edge
of the Sahara desert, the separation of vegetation zones
was more complicated in eastern and southern Africa,
where the mixture of zones is more complex. In such
areas, vegetation data were used in conjunction with
expert opinion and historical information about virus Niger
circulation. Insucient data were available to allow an
estimation of an elevation limit for yellow fever risk Vegetation line
Shrublands
in Africa. Savannah
Agadez
Initial working group decisions based on yellow fever Grasslands
case data, serological evidence, vegetation zones, and Croplands
Cropland or natural vegetation
elevation boundaries were used to produce an interim Barren or sparsely vegetated
harmonised global map published in WHOs 2009 ITH Rivers and lakes
publication and CDCs Health Information for Dia

International Travel 2010 (widely referred to as the Yellow Tahoua

Book).31,32 The working groups review of all countries in
South America and Africa continued after the
aforementioned publications were issued.
WHO convened the second consultation on yellow
fever and international travel in March, 2010 (the 2010
consultation), to review country-specic risk designations
and vaccine recommendations, criteria for the addition
or removal of countries and geographical regions in
annex 1 of the ITH publication, and the implications of
these criteria for the ITH. Future steps for yellow fever
risk mapping were also proposed.
This consultation resulted in three major outcomes.
First, the consultation adopted a new termlow potential
for exposure (table 1). Potential exposure to yellow fever
virus in these areas is expected in only rare
circumstanceseg, prolonged travel, heavy exposure to
mosquitoes, and inability to avoid mosquito bites.
Vaccine recommendations for travel to these areas should
be based on an assessment of travellers potential for
increased exposure to the virus on the basis of their
specic travel plans.
Second, the 2010 consultation suggested changing
the harmonised map published in WHOs ITH
publication and CDCs Health Information for
International Travel from a risk map to a vaccination
map. The yellow fever risk maps for South America
(including Panama and Trinidad and Tobago; gure 3)
and Africa (gure 4) will be published online and will
be used by the working group to periodically reassess
the four classications of risk. However, vaccination
maps (published in WHOs ITH [one for Africa and
one for the Americas] and CDCs Health Information
Tillabry Zinder
Maradi
Niamey Dosso
Figure 2: Use of vegetation to dene yellow fever risk areas on the southern border of the Sahara desert
Niger is used as an example here, but the same method was used to delineate the barren or sparsely vegetated
zones from other vegetation zones on the southern border of th Sahara desert.
international airport be considered to pose no risk for
yellow fever virus transmission, irrespective of the yellow
fever risk classication of the country in which the airport
is located. Although data for vectors infected with yellow
fever virus in airports are scarce, the working group
judged the risk to passengers transiting airports for 12 h
or less to be negligible.
Country-specic outcomes of the working group
The following countries in Africa and South America
had no change to their holoendemic classication and
are not discussed in more detail in this paper: Angola,
Benin, Burkina Faso, Burundi, Cameroon, Central
African Republic, Congo (Brazzaville), Cte dIvoire,
Equatorial Guinea, French Guiana, Gabon, Ghana,
Guinea, Guinea-Bissau, Guyana, Liberia, Nigeria, For the yellow fever risk maps
Rwanda, Senegal, Sierra Leone, Suriname, The Gambia, see http://www.who.int/YFrisk.
pdf
Togo, and Uganda. These countries either repeatedly
For the WHOs vaccination map
reported yellow fever infection in human beings or non-
for Africa see http://
human primates, had insucient subnational data or gamapserver.who.int/
inadequate surveillance systems to establish whether the mapLibrary/Files/Maps/ITH_YF_
virus was circulating at low levels in specic areas, or vaccination_africa.png

for International Travel) will provide more clarity and
ease of use for clinicians by designating where
vaccination is always recommended (endemic and
transitional areas), generally not recommended except
in specic circumstances (areas with low potential for
exposure), and never recommended (areas with no
risk; table 1).
Third, the 2010 consultation endorsed the working
groups proposal that a transit time of 12 h or less in an
were ecologically similar to adjacent countries with risk For the WHOs vaccination map
for the Americas see http://
for yellow fever virus transmission. Cape Verde and
gamapserver.who.int/
Djibouti were also reviewed, and no change was mapLibrary/Files/Maps/ITH_YF_
recommended to their classication of no risk. vaccination_americas.png
The working group proposed changes to the risk For CDCs vaccination map see
classications of the countries outlined in table 2. http://wwwnc.cdc.gov/travel/
yellowbook/2012/chapter-3-
Selected countries with the most substantial changes to
infectious-diseases-related-to-
their risk classication are described below to show the travel/yellow-fever.htm#2853
process and complexity of assigning risk. A full

www.thelancet.com/infection Vol 11 August 2011 625

 Review

similar epizootic expansion occurred in border areas of

Trinidad and Tobago
Brazil (Paran) and Paraguay. Yellow fever was widely
Panama Guyana detected in non-human primates in the districts of
Suriname Misiones and Corrientes, and at least ve human cases
Venezuela were conrmed in Misiones in areas aected in 1966. In
French Guiana view of these periodic expansions of epizootic activity
Colombia
and subsequent human cases, all departments of
Equador
Misiones and selected departments of Corrientes were
classied as transitional; selected departments of Chaco,
Jujuy, Formosa, and Salta were classied as having low
potential for exposure. All other areas of the country were
classied as posing no risk.
In Brazil, the Amazon region is holoendemic for yellow
Peru Brazil fever, as are areas bordering this region (eg, Maranho,
Tocantins, western Bahia State, and the Distrito Federal
Bolivia [Brasilia])all these areas are regarded as endemic.
Regions in the south, including the grassland areas of the
Pantanal of Mato Grosso do Sul, western So Paulo,
Paran, Santa Catarina, and Rio Grande do Sul, have
Paraguay
intermittent yellow fever virus activity when there is
southward epizootic expansion of the virus. These areas
Chile were classied as transitional. In the endemic areas in
Brazil, routine immunisation has been practised for
many years and most infections are in unvaccinated
Argentina
Uruguay migrants. Several yellow fever cases have been reported
in unvaccinated tourists entering the endemic region
from the Europe or USA.3436
Rivers and lakes Areas of Colombia east of the Andes and lower than
Yellow fever virus transmission risk 2300 m were classied as endemic for yellow fever, except
Endemic
Transitional
for the arid Guajira Peninsula (Uribia), which is probably
Low potential for exposure unsuitable for Haemagogus spp mosquitoes. The
No risk municipalities bordering Panama (Acandi, Unquia,
Jurado, and Riosucio) in Choc Department were
reclassied as transitional because during the late 1940s
outbreaks occurred in the Antioquia Department in
Colombia, and in eastern Panama, suggesting that
Figure 3: Areas with risk of yellow fever virus transmission in South America, 2010 conditions in these municipalities could support the
transmission of yellow fever virus.37 The Pacic coastal
description of the rationale for changes to risk region has had no reports of human cases, and no
classications for all countries is beyond the scope of this serological data exist from which to establish past
See Online for webappendix report, but is included in the webappendix (pp 12). presence of the virus. However, surveillance has been
restricted or absent in this highly forested area, which is
South America ecologically suitable for yellow fever virus transmission.
After reporting of yellow fever was instituted in 1927, the Because this region is positioned between the transitional
rst ocial notication of human cases in Argentina and endemic areas in the north of Colombia and the area
occurred in 1966. However, during the extensive 1948 with low potential for exposure in the south in Ecuador
epizootic in Brazil, the virus was detected in the Misiones (gure 3), the entire departments of Narino, Cauca, and
Province in Argentina, and one person with yellow fever Valle de Cauca, and all municipalities of the Choc
was identied in Campos de Taranco.33 In 196566, Department, except for those bordering Panama, were
another epizootic was detected in southern Brazil and classied as having low potential for exposure. The cities
northern Argentina, with 54 cases of yellow fever in of Barranquilla, Cartagena, Cali, and Medelln were
human beings reported from Misiones and Corrientes classied as areas of low potential for exposure because
provinces during 196567; suspected cases and the they are large urban areas with good surveillance and
presence of yellow fever vectors and non-human primate restricted potential for Haemogogus spp activity.
hosts were recorded in surrounding provinces.33 In 2001, In Ecuador, areas east of the Andes below 2300 m were
an epizootic occurred in border areas of Brazil, but no included in the endemic areas, on the basis of ecology
human cases were reported in Argentina. In 200708, a (Amazonian forest) and the repeated notication of

626 www.thelancet.com/infection Vol 11 August 2011

 Review

Algeria Libya Egypt

Western Sahara
Saudi Arabia

Mali
Mauritania
Niger Chad Eritrea
Cape Verde

Yemen
Senegal
The Gambia
Burkina Faso Sudan Djibouti
Guinea-Bissau Guinea
Nigeria Somalia
Cte Central Ethiopia
Ghana South Sudan
DIvoire African Republic
Sierra Leone
Benin Cameroon
Liberia Togo
Democratic Republic
So Tom and
of the Congo
Prncipe* Uganda Kenya
Gabon Rwanda

Equatorial Guinea Burundi

Rivers and lakes
Yellow fever virus transmission risk Congo Tanzania
Endemic
Low potential for exposure Seychelles
Malawi
No risk
Comoros
Angola
Zambia Mayotte

Zimbabwe

Namibia Botswana Madagascar

Mozambique
Swaziland
South Africa
Figure 4: Areas with risk of yellow fever virus transmission in Africa, 2010
*So Tom and Prncipe was classied as low potential for exposure.

human cases of yellow fever. Much like in Colombia, the
coastal areas were classied as areas with low potential
for exposure. The cities of Guayaquil and Quito and the
Galpagos Islands were though to have no risk, either
because of elevation or distance from an endemic or
transitional zone.
Previously, the region of Panama to the east of the
Canal Zone was classied as an endemic area. Cases of
yellow fever in human beings (sporadic individual cases
or clusters of cases) have been reported at long intervals
during expansions of virus transmission from bordering
endemic areas. Yellow fever outbreaks were recorded in
Panama in 1948, 195657, and 1974.38,39 Epizootics in 1948
aected the entire country, whereas the outbreak in
195657 was conned to eastern Panama. Similarly, a
third epizootic wave with four associated human cases in
Darin Province in 1974 did not reach the Panama Canal.
Whether the virus is permanently present in Panama or
is periodically introduced during infrequent epizootic
waves from South America is unclear. However, yellow
fever vectors and non-human primates are present in
this area, the ecological setting in which the virus is
transmitted has not changed, and surveillance of
infections in human beings, although improving,
inherently lacks sensitivity. Additionally, routine
vaccination of infantsimplemented in the eastern part
of the country since 1974has led to high levels of
immunity in the population, eliminating the disease in
people who live in the area. However, the virus
presumably still circulates in forests and is capable of
causing disease in unvaccinated people such as travellers.
Therefore, despite the absence of reported human cases
since 1974, travellers to eastern Panama could risk yellow
fever virus infection, especially during extensive outdoor
activity. Consequently, areas east of the canal were
classied as transitional.
Southeastern Paraguay, northern Argentina, and
southern states of Brazil have a history of intermittent
epizootic yellow fever, which often result in infections in
human beings. From 1927 to 2007, the only year in which
human cases of yellow fever were reported in Paraguay
was 1974, when nine cases of were reported from Amambay
Department, which borders Brazil.40 In 2008, 24 individuals
from the departments of San Pedro and Caaguaz, and the
urban area of Laurelty, near Asuncin, were reported as
having yellow fever, eight of whom died.25 Both the 1974
and 2008 outbreaks resulted from epizootics that began in
Brazil. Unrecognised sporadic cases might have occurred
in Paraguay in other years. Furthermore, whether or not
enzootic transmission continues after recognised outbreaks
is not clear. Although cases of human disease have not
been reported in northwestern Paraguay, this region is

www.thelancet.com/infection Vol 11 August 2011 627

 Review
bordered by endemic areas in Bolivia and Brazil. Because
of these reports of yellow fever virus in Paraguay and in
neighbouring countries during the past 3 years, all of
Paraguay was classied as transitional. The city of Asuncion
was regarded as an area with low potential for exposure
because the outbreak in Asuncin in 2008 was a result of
epizootic expansion into the northern part of the country
and subsequent translocation of the virus into the city.
Africa
Most of the Democratic Republic of the Congo is regarded
as endemic, because many outbreaks have been reported
in the country since 1912.41 The only controversial area is
Katanga Province in the south of the country, which has
been included and excluded from various yellow fever
risk maps as an endemic area. No human cases have
been reported from Katanga Province. Although yellow
fever antibodies were absent in one location
(Elizabethville) in 1934,42 such antibodies were detected
in 215% of adults at six of 14 locations in Katanga
Province in 195153.43 Without more up-to-date data for
yellow fever virus activity and because this region is
contiguous with endemic areas of the country to the
north and the western region of Zambia (an area of low
potential for exposure) to the southeast, it is viewed as an
area with low potential for exposure.
In the past, Eritrea has been both included and excluded
from yellow fever risk maps. Although no cases have
been reported in Eritrea, serosurveys in 194243 detected
neutralising antibodies in children and adults from seven
of 15 locations, with an overall seroprevalence of 49% in
children younger than 15 years.43,44 These ndings were
conrmed during the 195354 serosurvey,43,45 when 6% of
children were seropositive. Yellow fever vectors and
Previous classication 2010 consultation on yellow fever and international travel revised classications
Africa
Democratic Republic Endemic (whole country) Endemic: all areas except as mentioned below
of the Congo Low potential for exposure: Katanga Province
Eritrea No risk (whole country) Low potential for exposure: Anseba, Debub, Gash Barka, Mae Kel, and Semenawi Keih Bahri states
No risk: all other areas not listed above, including Dahlak Archipelagos
Ethiopia Endemic (whole country) Endemic: all areas except as mentioned below
Low potential for exposure: Afar and Somali provinces
Kenya Endemic (whole country) Endemic: all areas except as mentioned below
Low potential for exposure: the entire North Eastern Province; states of Kili, Kwale, Lamu, Malindi, and Tanariver, in the
Coast Province; and the cities of Nairobi and Mombasa
So Tom and Endemic (whole country) Low potential for exposure: whole country
Prncipe
Somalia Endemic (whole country) Low potential for exposure: Bakool, Banaadir, Bay, Galguduud, Gedo, Hiiraan, Lower Jubabada, Middle Jubabada, Middle
Shabelle, and Lower Shabelle regions
No risk: all other areas not listed above
Tanzania Endemic (whole country) Low potential for exposure: whole country
Zambia No risk (whole country) Low potential for exposure: North-Western and Western provinces
No risk: all other areas not listed above
628
non-human primate hosts are present in Eritrea, and the
western districts are characterised by savannahs
conducive to transmission of yellow fever virus by Aedes
spp mosquitoes that breed in tree holes. Therefore, the
working group classied the western region as having a
low potential for exposure, and the rest of the country
where for ecological reason, yellow fever vectors are not
expected to be supportedas having no risk.
Somalia had previously been classied as endemic in
the southern part of the country (WHO) or the entire
country (CDC), despite the absence of reported human
cases. A low prevalence of yellow fever antibodies (37%)
was recorded in adults in southeastern Somalia (Middle
Shabelle District) in 1942,44 and a 196667 serosurvey
showed neutralising antibodies (with a prevalence of
85%) also in Middle Shabelle District (near Mogadishu).46
Furthermore, south and south-central Somalia probably
have enough rainfall and vegetation to support
transmission of the virus. Therefore, the working group
designated districts in the south of Somalia
(gure 4; table 2) as areas with low potential for exposure.
The northern areas of Somalia are ecologically
unfavourable for transmission of yellow fever virus and
therefore have no risk. This view is supported by the
absence of serological evidence for human infection in
adjacent Djibouti.43
Tanzania was previously classied as endemic.
However, no cases of yellow fever in human beings or in
non-human primates have been reported. The only
evidence for virus activity comes from serological surveys
done in the 1940s, which showed a low prevalence of
seropositivity in children and adults (<5%).21,47 Positive
serum samples were also detected in the 1940s in regions
bordering Rwanda and in Moshi (in adults only). A
Listed in revised
annex 1 (2011) of
International Travel
and Health29
Yes
No
Yes
Yes
No
No
No
No
(Continues on next page)
www.thelancet.com/infection Vol 11 August 2011
 Review

Previous classication 2010 consultation on yellow fever and international travel revised classications Listed in revised
annex 1 (2011) of
International Travel
and Health29
(Continued from previous page)
South America
Argentina Transitional (specic Transitional: all departments of Misiones; and Departments of Bern de Astrada, Capital, General Alvear, General Paz, Yes
regions only) Ituzaing, Itat, Paso de los Libres, San Cosme, San Miguel, San Martn and Santo Tom in Corrientes Province
Low potential for exposure: all departments of Formosa Province; Department of Bermejo in Chaco Province; Departments
of Ledesma, Santa Brbara, San Pedro, and Valle Grande in Jujuy Province; and Departments of Anta, General Jos de San
Martn, Oran, and Rivadavia in Salta Province
No risk: areas above 2300 m and all areas not listed above
Brazil Endemic (specic regions Endemic: entire states of Acre, Amap, Amazones, Distrito Federal (including the capital city of Braslia), Gois, Maranho, Yes
only) Mato Grosso, Mato Grosso do Sul, Minas Gerais, Par, Rondnia, Roraima, and Tocantins; and designated areas of Bahia,
Paran, Piau, and So Paulo
Transitional: designated areas of Santa Catarina and Rio Grande do Sul states
No risk: all other areas not listed above, including the cities of Fortaleza, Recife, Rio de Janeiro, Salvador, and So Paulo
Colombia Endemic (whole country) Endemic: all areas except as mentioned below Yes
Transitional: Acandi, Unguia, Jurado, and Riosucio municipalities in the Choco department
Low potential for exposure: entire departments of Narino, Cauca, and Valle de Cauca; the Alto Baud, Atrato, Bagad, Baha
Solano, Bajo Baud, Beln de Bajir, Bojay, Carmen del Darin, Crtegui, Condoto, El Cantn de San Pablo, El Carmen de
Atrato, Istmina, Litoral del San Jun, Llor, Medio Atrato, Medio Baud, Medio San Jun, Nvita, Nuqu, Quibd, Ro Ir, Ro
Quito, San Jos del Palmar, Sip, Tad, and Unin Panamericana municipalities of the Choco Department; and the cities of
Barranquilla, Cartegena, Cali, and Medellin
No risk: areas above 2300 m, Uribia municipality in the La Guajira department, and the city of Bogot
Ecuador Endemic (specic regions Endemic: entire Morona-Santiago, Orellana, Pastaza, Napo, Sucumbios, and Zamora-Chinchipe provinces Yes
only) Low potential for exposure: entire provinces of Esmeraldas, Guayas, Manabi, and Los Rios, and designated areas of the
provinces of Azuay, Bolivar, Canar, Carchi, Chimborazo, Cotopaxi, El Oro, Imbabura, Loja, Pichincha, and Tungurahua
No risk: Areas above 2300 m, the cities of Guayaquil and Quito, the Galpagos Islands, and all areas not listed above
Panama Endemic (specic regions Transitional: entire comarcas (autonomous territories) of Ember and Kuna Yala, the entire province of Darin, and areas of Yes
only) the provinces of Coln and Panam that are east of the Canal Zone
No risk: city of Panama, the Canal Zone, San Blas Islands, Balboa Islands, and all areas not listed above
Paraguay Endemic (specic regions Transitional: whole country except as mentioned below Yes
only) Low potential for exposure: city of Asuncin
Peru Endemic (specic regions Endemic: entire regions of Amazonas, Loreto, Madre de Dios, San Martin, and Ucayali and designated areas of Ancash, Yes
only) Apurimac, Ayacucho, Cajamarca, Cusco, Huancavelica, Huanuco, Junin, La Libertad, Pasco, and Puno regions
Transitional: designated areas of Piura
Low potential for exposure: entire regions of Tumbes and Lambayeque, and designated areas of Cajamarca and Piura
regions
No risk: areas above 2300 m and all areas listed above
Trinidad and Tobago Endemic (whole country) Endemic: all areas except as mentioned below Yes
Low potential for exposure: city of Port of Spain
No risk: Tobago
Venezuela Endemic (specic regions Endemic: all areas except as mentioned below Yes
only) Low potential for exposure: Aragua, Carabobo, Miranda, Vargas, and Yaracuy, and the Distrito Federal
No risk: entire states of Falcon and Lara; the peninsular section of the Paez municipality of Zuila Province; Margarita Island;
and cities of Caracas and Valencia

Vaccination is recommended for travellers visiting endemic or transitional areas. In general, vaccination is not recommended for travellers whose itineraries are restricted to areas with low potential for exposure.
Although not generally recommended for travellers to areas with low potential for exposure, vaccination might be considered for a small subset of travellers whose itinerary would place them at increased risk
of exposure to yellow fever virus, such as prolonged travel, heavy exposure to mosquitoes, or inability to avoid mosquito bitesrisk of exposure should be weighed against individual risk factors for
vaccine-associated adverse events (eg, age, immune status) when deciding to vaccinate. Vaccination is not recommended for travellers whose itineraries are restricted to areas regarded as having no risk.

Table 2: Classications for selected areas with risk for transmission of yellow fever virus

survey on Zanzibar done in 195153 detected neutralising
antibodies in two of 55 unvaccinated children with no
history of travel to the mainland.43 Because of the absence
of human cases and low prevalence of antibodies detected
in serosurveys, Tanzania was classied as having low
potential for exposure.
Western Zambia was designated as endemic on WHO
and CDC maps until 2005, when for unclear reasons, it
was removed from the lists of areas or countries with risk
for transmission of yellow fever virus. Although no
conrmed cases have been ocially reported from the
country, a suspected case was described from the
North-Western Province in 1943.48 Many locations in the
western part of Zambia in the Zambezi River basin were
surveyed in 1944,44 and again in 195153; neutralising
antibodies were detected with a seroprevalence up to
18%.1,43 In view of this information and the fact that
neighbouring areas in Angola and the Democratic
Republic of the Congo are designated as having yellow
fever risk, the working group reclassied the North

www.thelancet.com/infection Vol 11 August 2011 629

 Review
Western and Western provinces as areas with low
potential for exposure.
Because serological evidence from surveys done
6075 years ago was the principal rationale for the
designation of all or parts of So Tom and Prncipe,
Tanzania, Zambia, Somalia, and Eritrea as areas with a
low potential for exposure, the relevance of such historical
data should be considered. During this time, ecological
changes such as land use changes, reduced the availability
of breeding sites in tree holes, reduced populations of
specic non-human primates, and climate change could
have altered the dynamics of yellow fever virus
transmission. However, no available evidence suggest that
such changes have occurred or aected virus transmission.
Another limitation of the remote serological data is that
they were derived by use of undiluted or minimally diluted
(a 1:10 dilution) human serum samples tested against only
yellow fever virus in a mouse neutralisation test, raising
the possibility that detected antibodies could have been
caused by cross-reactions with heterologous aviviruses.
These concerns are most relevant for areas of uncertain
risk at the borders of endemic zones. However, in the
absence of more up-to-date serosurvey data, including
results from tests for multiple aviviruses, no evidence
refutes the data from 6075 years ago.
Special situations outlined by the working group
Although Central America and western Panama have
reported yellow fever cases in the past, they have been
classied by the working group as having no risk, on the
basis of the following considerations. First, no yellow
fever virus activity (ie, in human beings, non-human
primates, or mosquitoes) has been reported for an
extended period of time (ve to eight times the typical
cycle of re-emergence of epizootic yellow fever in tropical
America). The interval between epizootics in South
America varies, but is generally 710 years.49 Second, after
the elimination of yellow fever in urban areas in this
region by 1925, the virus was not detected until its
introduction from Panama in 1948, with an ensuing
spread into Central America that ended in 1954. Third,
natural barriers prevent the introduction of the virus
across the Canal Zone, with the disease disappearing
from Central America west of the Canal Zone shortly
after the last event was reported in 1956.50 Several groups
of researchers with active eld and surveillance
programmes, including the Gorgas Memorial
Laboratories and the Middle America Research Unit,
have not detected the virus west of the Canal Zone,
suggesting that persistent virus activity in an enzootic
cycle has not occurred since.51
Cities with no risk or low potential for exposure
The working group identied specic cities (table 2),
some of which are major tourist destinations, as posing
little to no risk for yellow fever virus transmission.
Although A aegypti might be present, posing a theoretical
630
risk for urban transmission, the disease has not been
detected in these cities, and surveillance would be
expected to promptly identify cases. Therefore, they were
designated as no risk or low potential for exposure.
Implications for the ITH and national
immunisation policies
The working group agreed that countries with areas with
only low potential for exposure be excluded from the list
of countries with risk in annex 1 of the ITH publication.
Such exemptions apply to Eritrea, So Tom and Prncipe,
Somalia, Tanzania, and Zambia (table 2). Yellow fever
vaccination will generally not be recommended for travel
to these countries, unless travellers itineraries indicate
potentially increased risk of exposure and the benet of
vaccination outweighs the risk of vaccine-associated
adverse events (eg, age, altered immune status).17
This change to annex 1 of the ITH publication has
implications for vaccine entry requirements for travellers
from So Tom and Prncipe, Somalia, and Tanzania who
are travelling outside their countries (Eritrea and Zambia
were not previously listed). The working group
recommends that travellers arriving from these countries
do not need to provide evidence of vaccination. However,
according to the International Health Regulations,
countries with vulnerable populations and susceptible
vector species can dene their own yellow fever vaccine
entry requirements.
The ndings of the working group regarding the
geographical risk for yellow fever might also aect
countries national immunisation policies. Priority
setting for vaccination campaigns and introduction of
yellow fever vaccine in infant immunisation schedules
have always relied on the ocial WHO maps, and the
new classication will need to be taken into account
during formulation of national vaccination policies.3,52
Additionally, when gaps in information exist, countries
are encouraged to pursue eld research such as
serological surveys and detection of the virus in vectors
and non-human primates to guide the development of
risk maps and immunisation policies in the future.
Concluding remarks
The working group knows of no other systematic review of
all countries considered to have risk for yellow fever virus
transmission. Through the WHO consultations and the
Informal Working Group on Geographic Risk for Yellow
Fever, criteria were developed for risk of virus transmission,
countries and geographical regions with risk for virus
transmission were reassessed with these criteria, and
vaccine recommendations for travellers were made on the
basis of yellow fever risk. This process provides transparent
decision-making and clear descriptions of areas with risk
for yellow fever virus transmission. These data provide the
framework underlying the yellow fever vaccination maps
that will be published in CDCs Health Information for
International Travel and WHOs ITH publications. By
www.thelancet.com/infection Vol 11 August 2011

Search strategy and selection criteria
The working group identied studies and reports that
contained potentially useful data about the transmission of
yellow fever virus by searching PubMed, reviewing relevant
bibliographies, consulting subject matter experts, assessing
unpublished data (including serosurvey, entomological, and
disease incidence data), and examining ocial case reports
from national or international health organisations (eg,
WHO). To capture all historical data, we searched PubMed up
to May, 2010, with the search term yellow fever. There were
no language restrictions on the PubMed search. Additional
references were sought from those papers bibliographies,
from subject matter experts, and from the personal
collections of the members of the working group.
presenting only vaccination maps in these publications,
clinicians will have clear guidance on where vaccination is
always recommended (balanced against any vaccine
precautions or contraindications), generally not
recommended, and not recommended. Because some of
the boundaries for areas with risk of yellow fever virus
transmission have changed, clinicians should thoroughly
review with travellers their itineraries and activities to
ascertain the potential exposure to yellow fever virus.
Decisions on whether to give a yellow fever vaccination
should take into account patients risk of infection, country
vaccination requirements, and the potential for serious
vaccine-associated adverse events.
The epidemiology of this vector-borne disease is
dynamic and subject to changes resulting from climate
change, including cyclical events aecting rainfall
patterns, and human factors, such as migration and air
travel. Many areas in the Americas, Africa, and Asia are
susceptible to the introduction and spread of yellow fever;
the establishment of dengue fever and chikungunya,
transmitted by A aegypti, in these areas shows that they
are also at risk for urban yellow fever. The monitoring of
countries or geographical regions with risk for
transmission is important. WHO continues to document
ndings of case reports, outbreaks, and scientic research
on yellow fever, and updates on disease activity in South
America and Africa are published regularly in the Weekly
Epidemiological Record.53 Yellow fever outbreaks are also
reported in the WHO Disease Outbreak News. The
working group will continue to incorporate this
information and use input from WHO member states to
make updates to yellow fever risk maps and to assess
vaccine recommendations for travellers. The working
group is also developing guidance for countries that want
to change their yellow fever risk classication. Finally, the
working group endorses eorts to strengthen disease
surveillance in aected regions and strongly encourages
countries to undertake surveillance research and surveys
to improve the knowledge base and subsequent analysis
of yellow fever risk.
www.thelancet.com/infection Vol 11 August 2011
Review
Contributors
ESJ contributed to the primary writing of the report, the data search,
gure creation, data analysis, data interpretation, and editing of the nal
paper. GP, MDG, DRH, JL, RFL, JES, OT, and AW-S contributed equally
to the writing of the report, gure creation, data analysis, data
interpretation, and editing of the nal paper. TPM contributed to the
writing of the report, research, data review, and data analysis.
Conicts of interest
WHO provided travel support for ESJ, MDG, DRH, JES, OT, AW-S, and
TPM. DRH declares that his institution (the National Travel Health
Network and Centre) receives a registration fee from yellow fever
vaccination centres in England, Wales, and Northern Ireland as part of a
programme of registration, training, standards, and audit for yellow
fever centres. RFL declares that WHO receives funding from the Global
Alliance for Vaccines and Immunization for the Yellow Fever Initiative.
AW-S has been sponsored to attend conferences and has received
speakers fees from Sano Pasteur, Novartis, and GlaxoSmithKline.
TPM declares board membership, patents, and stock options for
Xcellerex. GP and JL declare that they have no conict of interests.
Acknowledgments
We thank WHO and PAHO for their help, including the coordination of
the Informal Working Group on Geographic Risk for Yellow Fever, and
the technical development from the WHO Public Health Information
and GIS team of the yellow fever risk maps shown here and the
vaccination maps produced in the WHO International Travel and
Health (Green Book) and the CDC Health Information for International
Travel (Yellow Book). We also thank the US Centers for Disease Control
and Prevention, the UK National Travel Health Network and Centre,
National University Singapore, Redeemers University in Nigeria,
European Centre for Disease Prevention and Control, and the Public
Health Agency of Canada. Specically, we would like to thank
Herv Zeller, Jennifer Geduld, William Perea, Fenella Avokey,
Martin Opoka, Nohelly Nombela, Sheila Nakpil, Patricia Njera-Aguilar,
Nina Marano, Gary Brunette, and Kevin Liske for their support of this
work. Mark Sotir, Ava Navin, Marc Fischer, and Clive Brown are
acknowledged for their careful review of the manuscript. Finally, we
thank authorities of the following countries for providing information,
valuable feedback, thoughtful critique, productive discussion, or
participation in consultations: Angola, Argentina, Benin, Bolivia, Brazil,
Burkina Faso, Burundi, Cameroon, Central African Republic, Chad,
Colombia, Congo (Brazzaville), Cte dIvoire, Democratic Republic of
the Congo, Ecuador, Equatorial Guinea, Eritrea, Ethiopia, French
Guiana, Gabon, Ghana, Guinea, Guinea-Bissau, Guyana, Kenya, Liberia,
Mali, Mauritania, Niger, Nigeria, Panama, Paraguay, Peru, Rwanda,
So Tom and Prncipe, Senegal, Sierra Leone, Somalia, Sudan,
Suriname, Tanzania, The Gambia, Togo, Trinidad and Tobago, Uganda,
Venezuela, and Zambia.
The Informal Working Group on Geographic Risk for Yellow Fever
The working group includes several participating experts, country
representatives, and organisations, including regular and extensive
contributions by: WHO headquarters and regional personnel
(Gilles Poumerol, Rosamund F Lewis, Johan Lemarchand, Otavio Oliva,
Patricia Njera-Aguilar, Luz Maria Vilca); US Centers for Disease Control
and Prevention (J Erin Staples, Mark D Gershman, and Emily S Jentes),
UK National Travel Health Network and Centre (David R Hill), National
University-Singapore (AW-S), Redeemers University-Nigeria (Oyewale For the WHO Disease Outbreak
Tomori), European Centre for Disease Prevention and Control News see http://www.who.int/
(Herv Zeller), and the Public Health Agency of Canada csr/don/en/index.html
(Jennifer Geduld). Gilles Poumerol organised the study and led the
groups activities during the entire period covered by this report
(200810).
References
1 WHO. Yellow fever reported cases. http://apps.who.int/
immunization_monitoring/en/globalsummary/timeseries/
tsincidenceyfe.htm (accessed Aug 11, 2010).
2 Robertson SE, Hull BP, Tomori O, Bele O, LeDuc JW, Esteves K.
Yellow fever: a decade of reemergence. JAMA 1996; 276: 115762.
3 WHO. Yellow fever vaccine: WHO position paper.
Wkly Epidemiol Rec 2003; 78: 34959.
631
 Review

4 Rosenzweig EC, Babione RW, Wisseman CL. Immunological
studies with group B arthropod-borne viruses, IV: persistence of
yellow fever antibodies following vaccination with 17D strain yellow
fever vaccine. Am J Trop Med Hyg 1963;12: 23035.
5 Poland JD, Calisher CH, Monath TP, Downs WG, Murphy K.
Persistence of neutralizing antibody 3035 years after
immunization with 17D yellow fever vaccine.
Bull World Health Organ 1981; 59: 895900.
6 WHO. International Health Regulations, 2005. Geneva,
Switzerland: World Health Organization, 2007.
7 WHO. The state of world health: world health report. Geneva,
Switzerland: World Health Organization, 1996.
8 Monath TP, Cetron MS. Prevention of yellow fever in persons
traveling to the tropics. Clin Infect Dis 2002; 34: 136978.
9 Monath TP, Cetron M, Teuwen D. Yellow fever. In: Plotkin SA,
Orenstein A, Ot P, eds. Vaccines, 5th edn. Philadelphia:
Elsevier Saunders, 2008: 9591055.
10 Vasconcelos PF, Luna EJ, Galler R, et al. Serious adverse events
associated with yellow fever 17DD vaccine in Brazil: a report of two
cases. Lancet 2001; 358: 9197.
11 Adhiyaman V, Oke A, Cefai C. Eects of yellow fever vaccination.
Lancet 2001; 358: 190708.
12 Troillet N, Laurencet F. Eects of yellow fever vaccination. Lancet
2001; 358: 190809.
13 Chan RC, Penney DJ, Little D, Carter IW, Roberts JA,
Rawlinson WD. Hepatitis and death following vaccination with
17D-204 yellow fever vaccine. Lancet 2001; 358: 12122.
14 Martin M, Tsai TF, Cropp B, et al. Fever and multisystem organ
failure associated with 17D-204 yellow fever vaccination: a report of
four cases. Lancet 2001; 358: 98104.
15 Werfel U, Popp W. Eects of yellow fever vaccination. Lancet 2001;
358: 1909.
16 Centers for Disease Control and Prevention. Fever, jaundice, and
multiple organ system failure associated with 17D-derived yellow
fever vaccination, 19962001. MMWR 2001; 50: 64345.
17 Lindsey NP, Schroeder BA, Miller ER, et al. Adverse event reports
following yellow fever vaccination. Vaccine. 2008; 26: 607782.
18 Staples JE, Gershman M, Fischer M. Yellow fever vaccine:
recommendations of the advisory committee on immunization
practices (ACIP). MMWR Recomm Rep 2010; 59: 127.
19 McMahon AW, Eidex RB, Marn AA, et al. Neurologic disease
associated with 17D-204 yellow fever vaccination: a report of
15 cases. Vaccine 2007; 25: 172734.
20 WHO. Yellow Fever vaccine safety. http://www.who.int/vaccine_
safety/topics/yellow_fever/en/index.html (accessed April 20, 2011).
21 Sawyer WA. The present geographic distribution of yellow fever and
its signicance. Harvey Lectures 1934; 30: 6692.
22 Rogers DJ, Wilson AJ, Hay SI, Graham AJ. The global distribution
of yellow fever and dengue. Adv Parasitol 2006; 62: 181220.
23 Centers for Disease Control and Prevention. Health information for
international travel 20052006. Atlanta: US Department of Health
and Human Services, Public Health Service, 2005.
24 WHO. International travel and health. Geneva, Switzerland: WHO
Press, 2005.
25 WHO. Outbreak news: yellow fever, Paraguay. Wkly Epidemiol Rec
2008; 83: 105.
26 Barrera Oro JG, Coronado GA, Gutman Frugone LF, Vilches YA.
Isolation of the yellow fever virus in Argentina: etiology of the
epidemic in Corrientes and Misiones, 1966. Medicina 1966;
26: 23945.
27 WHO. Outbreak news: yellow fever, Republic of the Congo.
Wkly Epidemiol Rec 2009; 84: 161.
38 WHO. Yellow fever in the Central African Republic, 2009. http://
www.who.int/csr/don/2009_12_01/en/print.html
(accessed Aug 10, 2010).
29 WHO. International travel and health, 2010 edn. Geneva: World
Health Organization, 2010.
30 United States Geological Survey. GTOPO30, a global digital
elevation model. http://eros.usgs.gov/#/Find_Data/Products_and_
Data_Available/gtopo30_info (accessed Dec 10, 2008).
31 WHO. International Travel and Health. Geneva: World Health
Organization Press, 2009.
32 US Centers for Disease Control and Prevention. CDC Health
Information and International Travel 2010. Atlanta: US Department
of Health and Human Services, Public Health Service, 2009.
33 Anonymous. Proceedings of the yellow fever conference: yellow
fever conference; 1955. Am J Trop Med Hyg 1955; 4: 571661.
34 Hall P, Fojtasek M, Pettigrove J, et al. Fatal yellow fever in a traveler
returning from Amazonas. MMWR 2002; 51: 324.
35 Barros ML, Boecken G. Jungle yellow fever in the central Amazon.
Lancet 1996; 348: 96970.
36 McFarland JM, Baddour LM, Nelson JE, et al. Imported yellow fever
in a United States citizen. Clin Infect Dis 1997; 25: 114347.
37 Soper R. Review of the yellow fever menaceyellow fever
conference (1954; Washington DC). Am J Trop Med Hyg 1955;
4: 573582.
38 Trapido H, Galindo P. The epidemiology of yellow fever in
Middle America. Exp Parasitol 1956; 5: 285323.
39 Monath TP. Yellow fever: Victor, Victoria? Conqueror, conquest?
Epidemics and research in the last forty years and prospects for the
future. Am J Trop Med Hyg 1991; 45: 143.
40 Pan American Health Organization. Yellow fever: cases in
Colombia, Panama, and Paraguay. PAHO Bulletin 1974; 8: 27071.
41 Courtis G, Osterreith P, Blanes Ridama G. Islement du virus
de la vre jaune au Congo Belge. Ann Soc Belge Trop 1960;
40: 2940.
42 Beeuwkes H, Mahay A, Burke A, Paul J. Yellow fever protection
test surveys in the French Cameroons, French equatorial Africa, the
Belgian Congo, and Angola. Trans R Soc Trop Med Hyg 1934;
28: 23358.
43 Bonnel PH, Deutschman Z. Yellow fever in Africa during recent
years. Bull World Health Organ 1954; 11: 32589.
44 Mahay AF, Smithburn K, Hughes T. The distribution of immunity
to yellow fever in central and east Africa.
Trans R Soc Trop Med Hyg 1946; 40: 5782.
45 Chabaud MA, Ovazza M. Yellow fever in the Federation of Ethiopia
& Eritrea; present-day epidemiological data.
Bull World Health Organ 1958; 19: 721.
46 Henderson BE, Metselaar D, Cahill K, Timms GL, Tukei PM,
Williams MC. Yellow fever immunity surveys in northern Uganda
and Kenya and eastern Somalia, 196667. Bull World Health Organ
1968; 38: 22937.
47 Salah S, Fox E, Abbatte EA, Constantine NT, Asselin P, Soliman AK.
A negative human serosurvey of haemorrhagic fever viruses in
Djibouti. Ann Inst Pasteur Virol 1988; 139: 43942.
48 Robinson GG. A note on mosquitoes and yellow fever in Northern
Rhodesia. East Afr Med J 1950; 27: 28488.
49 Taylor RM. Epidemiology. In: Strode GK, ed. Yellow fever.
New York: McGraw Hill; 1951: 54338.
50 De Rodaniche E, Galindo P. Isolation of yellow fever virus from
Haemagogus mesodentatus, H equinus and Sabethes chloropterus
captured in Guatemala in 1956. Am J Trop Med Hyg 1957; 6: 23237.
51 Galindo P, Derodaniche E. Surveillance for sylvan yellow fever
activity in Panama (19571961). Am J Trop Med Hyg 1964; 13: 84450.
52 Anonymous. Yellow fever in Africa and South America, 2007.
Wkly Epidemiol Rec 2009; 84: 97104.
53 WHO. Yellow fever in Africa and Central and South America,
20082009. Wkly Epidemiol Rec 2011; 86: 2536.

632 www.thelancet.com/infection Vol 11 August 2011

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.