The first yellow fever epidemic hit Philadelphia in 1793, killing approximately 5,000 people. The pandemic that emerged so close to New York City (NYC) prompted the creation of the first Board of Health Department. To prevent the spread of yellow fever in NYC, action was taken to quarantine boats coming from Philadelphia. Although early efforts helped delay the epidemic, in the summer of 1795 cases of yellow fever began to emerge in Manhattan. The yellow fever epidemic which lasted until 1803, varied in severity. It reached epidemic proportions three times: in 1795, 1799, and 1803 claiming thousands of lives over the course of its presence in NYC. Upon infection, most victims would experience headaches, followed by severe exhaustion, high fever and slowed heart rate. This period was followed by a remission stage and then by delirium. During the delirium stage, victims acquired a characteristic yellow hue on their skin and pupils. In final stages, a vomiting of black bile occurred and was followed by death. Despite the presence of yellow fever in NYC since 1795, many people were unwilling to admit that an epidemic was on the horizon. A reluctance to publicize the fever epidemic was probably due to fear of business losses and to prevent a mass exodus from NYC. However, many wealthy residents fled to the country side as yellow fever reached epidemic proportions. During this time, very little was known about the origins of yellow fever. Physicians speculated that it was born out of unsanitary condition in slums, or brought to North America from the West Indies. Some even hypothesized that it was caused by rotting coffee. By the end of the 18th Century, doctors had been speculating that it might be transmitted through mosquitos, which were often found in high numbers in infected neighborhoods. However, a belief that yellow fever was not contagious, gave a false sense of security to many wealthy New Yorkers at the time. Efforts by the Board of Health were minimal and limited to the use of quarantines on infected ships; although cleanup efforts around infected neighborhoods were occasionally carried out. The first Board of Health, created specifically to combat yellow fever, would be inactive until the cholera epidemics in 1832 and onwards. However, before a well-organized and funded Board of Health could be developed, the government paid little to no attention to the City's health, in periods were epidemics were not immediately threatening the populace.