Yellow Fever - Once Again on the Radar Screen in the Americas

Community Composition and Year-round Abundance of Vector Species of Mosquitoes make Miami-Dade County, Florida a Receptive Gateway for Arbovirus entry to the United States

Vector-borne diseases are a heavy burden to human-kind. Global warming and urbanization have a significant impact on vector-borne disease transmission, resulting in more severe outbreaks, and outbreaks in formerly non-endemic areas. Miami-Dade County, Florida was the most affected area in the continental United States during the 2016 Zika virus outbreak. Miami is an important gateway and has suitable conditions for mosquitoes year-round. Therefore, it was critical to establish and validate a surveillance system to guide and improve mosquito control operations. Here we assess two years of mosquito surveillance in Miami established after the 2016 Zika virus outbreak. Our results show that the most abundant mosquito species are either well adapted to urban environments or are adapting to it. The five most abundant species comprised 85% of all specimens collected, with four of them being primary vectors of arboviruses. Aedes aegypti and Culex quinquefasciatus were found year-round throughout Miami regardless of urbanization level, vegetation, or socioeconomic variations. This study serves as a foundation for future efforts to improve mosquito surveillance and control operations.

Purification of flavivirus VLPs by a two-step chomatographic process

Flaviviruses are enveloped viruses with positive-sense, single-stranded RNA, which are most commonly transmitted by infected mosquitoes. Zika virus (ZIKV) and yellow fever virus (YFV) are flaviviruses that have caused significant outbreaks in the last few years. Since there is no approved vaccine against ZIKV, and since the existing YF attenuated vaccine presents disadvantages related to limited supply and to rare, but fatal adverse effects, there is an urgent need for new vaccines to control these diseases. Virus-like particles (VLPs) represent a recombinant platform to produce safe and immunogenic vaccines. Thus, based on our experience of expressing in recombinant mammalian cells VLPs of most flaviviruses circulating in the Americas, this work focused on the evaluation of chromatographic purification processes for zika and yellow-fever VLPs. The clarified cell culture supernatant was processed by a membrane-based anion-exchange chromatography and then a multimodal chromatographic step. With this process, it was possible to obtain the purified VLPs with a yield (including the clarification step) of 66.4% for zika and 68.1% for yellow fever. DNA clearance was in the range of 99.8-99.9%, providing VLP preparations that meet the WHO limit for this critical contaminant. Correct size and morphology of the purified VLPs were confirmed by dynamic light scattering (DLS) and transmission electron microscopy (TEM). The promising results obtained for both zika and yellow fever VLPs indicate that this process could be potentially applied also to VLPs of other flaviviruses.

Biopesticides improve efficiency of the sterile insect technique for controlling mosquito-driven dengue epidemics

Various mosquito control methods use factory raised males to suppress vector densities. But the efficiency of these methods is currently insufficient to prevent epidemics of arbovirus diseases such as dengue, chikungunya or Zika. Suggestions that the sterile insect technique (SIT) could be "boosted" by applying biopesticides to sterile males remain unquantified. Here, we assess mathematically the gains to SIT for Aedes control of either: boosting with the pupicide pyriproxifen (BSIT); or, contaminating mosquitoes at auto-dissemination stations. Thresholds in sterile male release rate and competitiveness are identified, above which mosquitoes are eliminated asymptotically. Boosting reduces these thresholds and aids population destabilisation, even at sub-threshold release rates. No equivalent bifurcation exists in the auto-dissemination sub-model. Analysis suggests that BSIT can reduce by over 95% the total release required to circumvent dengue epidemics compared to SIT. We conclude, BSIT provides a powerful new tool for the integrated management of mosquito borne diseases.

Yellow fever (YF) vaccination does not increase dengue severity: A retrospective study based on 11,448 dengue notifications in a YF and dengue endemic region

BACKGROUND

We study the association between prior yellow fever immunization and clinical outcomes of dengue infections in individuals of varying sexes and ages. Serological interactions between dengue virus and other flaviviruses could drive antibody dependent enhancement, which is associated with disease severity in dengue infections. This effect may influence disease severity in individuals subsequently affected by related flaviviruses, such as dengue. We compare the severity of dengue episodes between patients vaccinated and non-vaccinated against yellow fever.

METHODS

We evaluated the severity of 11,448 lab-confirmed dengue cases reported in São José do Rio Preto, Brazil, in 7370 YF vaccinated patients compared to 4043 unvaccinated patients. We regressed dengue severity against YF vaccine status and a number of demographic, clinical, and laboratory variables as controls. We also evaluated the association between YF vaccination status and the clinical and laboratory symptoms of dengue patients.

RESULTS

We did not find any evidence of increased risk for severe dengue in patients vaccinated against YF (odds ratio = 1.00; 95% confidence interval = 0.87-1.14). Most of the variables analyzed did not have a statistically significant association with YF vaccination status.

CONCLUSIONS

We found no evidence that YF vaccination in dengue-endemic areas increases the risk of severe dengue fever.

Human antibody response to Zika targets type-specific quaternary structure epitopes

The recent Zika virus (ZIKV) epidemic in the Americas has revealed rare but serious manifestations of infection. ZIKV has emerged in regions endemic for dengue virus (DENV), a closely related mosquito-borne flavivirus. Cross-reactive antibodies confound studies of ZIKV epidemiology and pathogenesis. The immune responses to ZIKV may be different in people, depending on their DENV immune status. Here, we focus on the human B cell and antibody response to ZIKV as a primary flavivirus infection to define the properties of neutralizing and protective antibodies generated in the absence of preexisting immunity to DENV. The plasma antibody and memory B cell response is highly ZIKV type-specific, and ZIKV-neutralizing antibodies mainly target quaternary structure epitopes on the viral envelope. To map viral epitopes targeted by protective antibodies, we isolated 2 type-specific monoclonal antibodies (mAbs) from a ZIKV case. Both mAbs were strongly neutralizing in vitro and protective in vivo. The mAbs recognize distinct epitopes centered on domains I and II of the envelope protein. We also demonstrate that the epitopes of these mAbs define antigenic regions commonly targeted by plasma antibodies in individuals from endemic and nonendemic regions who have recovered from ZIKV infections.

Identification of Broad-Spectrum Antiviral Compounds by Targeting Viral Entry

Viruses are a major threat to human health and economic well-being. In recent years Ebola, Zika, influenza, and chikungunya virus epidemics have raised awareness that infections can spread rapidly before vaccines or specific antagonists can be made available. Broad-spectrum antivirals are drugs with the potential to inhibit infection by viruses from different groups or families, which may be deployed during outbreaks when specific diagnostics, vaccines or directly acting antivirals are not available. While pathogen-directed approaches are generally effective against a few closely related viruses, targeting cellular pathways used by multiple viral agents can have broad-spectrum efficacy. Virus entry, particularly clathrin-mediated endocytosis, constitutes an attractive target as it is used by many viruses. Using a phenotypic screening strategy where the inhibitory activity of small molecules was sequentially tested against different viruses, we identified 12 compounds with broad-spectrum activity, and found a subset blocking viral internalisation and/or fusion. Importantly, we show that compounds identified with this approach can reduce viral replication in a mouse model of Zika infection. This work provides proof of concept that it is possible to identify broad-spectrum inhibitors by iterative phenotypic screenings, and that inhibition of host-pathways critical for viral life cycles can be an effective antiviral strategy.

From hidden outbreaks to epidemic emergencies: the threat associated with neglecting emerging pathogens

Not all infectious disease outbreaks undergo full epidemiological investigations. In certain situations, the resultant lack of knowledge has led to the development of epidemics and public health emergencies. This review will examine six emerging pathogens including their history, present status, and potential to expand to epidemics. Recommendations to improve our understanding of these hidden outbreaks and others also will be provided in the context of health systems policy.

Lipid metabolism in insect disease vectors

More than a third of the world population is at constant risk of contracting some insect-transmitted disease, such as Dengue fever, Zika virus disease, malaria, Chagas' disease, African trypanosomiasis, and others. Independent of the life cycle of the pathogen causing the disease, the insect vector hematophagous habit is a common and crucial trait for the transmission of all these diseases. This lifestyle is unique, as hematophagous insects feed on blood, a diet that is rich in protein but relatively poor in lipids and carbohydrates, in huge amounts and low frequency. Another unique feature of these insects is that blood meal triggers essential metabolic processes, as molting and oogenesis and, in this way, regulates the expression of various genes that are involved in these events. In this paper, we review current knowledge of the physiology and biochemistry of lipid metabolism in insect disease vectors, comparing with classical models whenever possible. We address lipid digestion and absorption, hemolymphatic transport, and lipid storage by the fat body and ovary. In this context, both de novo fatty acid and triacylglycerol synthesis are discussed, including the related fatty acid activation process and the intracellular lipid binding proteins. As lipids are stored in order to be mobilized later on, e.g. for flight activity or survivorship, lipolysis and β-oxidation are also considered. All these events need to be finely regulated, and the role of hormones in this control is summarized. Finally, we also review information about infection, when vector insect physiology is affected, and there is a crosstalk between its immune system and lipid metabolism. There is not abundant information about lipid metabolism in vector insects, and significant current gaps in the field are indicated, as well as questions to be answered in the future.

Genomic and epidemiological monitoring of yellow fever virus transmission potential

The yellow fever virus (YFV) epidemic in Brazil is the largest in decades. The recent discovery of YFV in Brazilian Aedes species mosquitos highlights a need to monitor the risk of reestablishment of urban YFV transmission in the Americas. We use a suite of epidemiological, spatial, and genomic approaches to characterize YFV transmission. We show that the age and sex distribution of human cases is characteristic of sylvatic transmission. Analysis of YFV cases combined with genomes generated locally reveals an early phase of sylvatic YFV transmission and spatial expansion toward previously YFV-free areas, followed by a rise in viral spillover to humans in late 2016. Our results establish a framework for monitoring YFV transmission in real time that will contribute to a global strategy to eliminate future YFV epidemics.

Management and control of yellow fever virus: Brazilian outbreak January-April, 2018

Yellow fever virus (YFV) has a long history of causing human disease. Today, YFV is persevered in jungle environments with occasional sporadic human outbreaks in South America and periodic intermediate human transmissions with occasional urban outbreaks in sub-Saharan Africa. The ever-present risk of outbreak is primarily controlled for via vaccination coverage to vulnerable human populations. Global vaccine supplies have been strained in the setting of recent outbreaks in Africa and Brazil. The increasingly global community of today has placed an ever-growing tension on the management and control of YFV. A historic outbreak of YFV in Brazil is tracked from January to April 2018 using the International Society for Infectious Diseases' (ISID) Program for Monitoring Emerging Diseases (ProMed). A narrative summary is generated from the review of 29 ProMed reports pertaining to the key words yellow fever and Brazil. Significant topics addressed include urban proximity, vaccination dose sparing with 1/5th standard dose, international travellers, epizootic trends, vaccine hesitancy, and mass immunisation campaigns. These topics are reviewed in detail for the current outbreak in comparison to previous outbreaks. Through close attention to these topics the degree and extent of the current outbreak was attenuated.

Immunogenicity and Protection After Vaccination With a Modified Vaccinia Virus Ankara-Vectored Yellow Fever Vaccine in the Hamster Model

The highly efficacious live-attenuated 17D yellow fever (YF) vaccine is occasionally associated with rare life-threatening adverse events. Modified vaccinia virus Ankara (MVA), a non-replicating poxvirus, has been used as a vaccine platform to safely deliver various antigens. A MVA-based YF vaccine (MVA-BN-YF) was tested with and without a non-mineral oil adjuvant in a hamster model of lethal YF disease and protective efficacy of this vaccine was compared with the 17D vaccine. The vaccine candidate MVA-BN-YF generated a protective response in hamsters infected with YFV that was comparable to protection by the live 17D vaccine. Similar levels of neutralizing antibody were observed in animals vaccinated with either vaccine alone or vaccine with adjuvant. Significant improvement in survival, weight change, and serum alanine aminotransferase levels were observed in vaccinated hamsters when administered 42 and 14 days prior to challenge with Jimenez YF virus (YFV). Neutralizing antibodies induced by MVA-BN-YF were transferred to naïve hamsters prior to virus challenge. Passive administration of neutralizing antibody 24 h prior to virus infection resulted in significantly improved survival and weight change. A trend toward reduced liver enzyme levels was also observed. MVA-BN-YF, therefore, represents a safe alternative to vaccination with live-attenuated YFV.

Prediction and prevention of urban arbovirus epidemics: A challenge for the global virology community

The recent emergence and rapid spread of Zika virus in tropical regions of the Western Hemisphere took arbovirologists and public health officials by surprise, and the earlier transfers of West Nile and chikungunya viruses from the Old to the New World were also unexpected. These pandemics underscore the increasing threat of zoonotic arboviruses, especially those that are capable of entering into human-amplified, urban transmission cycles transmitted by Aedes (Stegomyia) aegypti and sometimes other Aedes (Stegomyia) spp. mosquitoes. This review serves as an introduction to a World Health Organization-sponsored conference to be held on June 18-19, 2018 in Geneva, titled "From obscurity to urban epidemics: what are the next urban arboviruses?" It is intended to set the stage and fuel discussions of future urban arbovirus threats, how we can predict these risks from known and unknown viruses, and what factors may change these risks over time.

The Good, the Bad, and the Shocking: The Multiple Roles of Dengue Virus Nonstructural Protein 1 in Protection and Pathogenesis

Dengue virus (DENV) is the most prevalent medically important mosquito-borne virus in the world. Upon DENV infection of a host cell, DENV nonstructural protein 1 (NS1) can be found intracellularly as a monomer, associated with the cell surface as a dimer, and secreted as a hexamer into the bloodstream. NS1 plays a variety of roles in the viral life cycle, particularly in RNA replication and immune evasion of the complement pathway. Over the past several years, key roles for NS1 in the pathogenesis of severe dengue disease have emerged, including direct action of the protein on the vascular endothelium and triggering release of vasoactive cytokines from immune cells, both of which result in endothelial hyperpermeability and vascular leak. Importantly, the adaptive immune response generates a robust response against NS1, and its potential contribution to dengue vaccines is also discussed.

Yellow fever in the diagnostics laboratory

Yellow fever (YF) remains a public health issue in endemic areas despite the availability of a safe and effective vaccine. In 2015–2016, urban outbreaks of YF were declared in Angola and the Democratic Republic of Congo, and a sylvatic outbreak has been ongoing in Brazil since December 2016. Of great concern is the risk of urban transmission cycles taking hold in Brazil and the possible spread to countries with susceptible populations and competent vectors. Vaccination remains the cornerstone of an outbreak response, but a low vaccine stockpile has forced a sparing-dose strategy, which has thus far been implemented in affected African countries and now in Brazil. Accurate laboratory confirmation of cases is critical for efficient outbreak control. A dearth of validated commercial assays for YF, however, and the shortcomings of serological methods make it challenging to implement YF diagnostics outside of reference laboratories. We examine the advantages and drawbacks of existing assays to identify the barriers to timely and efficient laboratory diagnosis. We stress the need to develop new diagnostic tools to meet current challenges in the fight against YF.

Yellow Fever Virus: Knowledge Gaps Impeding the Fight Against an Old Foe

Yellow fever (YF) was one of the most dangerous infectious diseases of the 18th and 19th centuries, resulting in mass casualties in Africa and the Americas. The etiologic agent is yellow fever virus (YFV), and its live-attenuated form, YFV-17D, remains one of the most potent vaccines ever developed. During the first half of the 20th century, vaccination combined with mosquito control eradicated YFV transmission in urban areas. However, the recent 2016-2018 outbreaks in areas with historically low or no YFV activity have raised serious concerns for an estimated 400-500 million unvaccinated people who now live in at-risk areas. Once a forgotten disease, we highlight here that YF still represents a very real threat to human health and economies. As many gaps remain in our understanding of how YFV interacts with the human host and causes disease, there is an urgent need to address these knowledge gaps and propel YFV research forward.

Follow up of a robust meta-signature to identify Zika virus infection in Aedes aegypti: another brick in the wall

The mosquito Aedes aegypti is the main vector of several arthropod-borne diseases that have global impacts. In a previous meta-analysis, our group identified a vector gene set containing 110 genes strongly associated with infections of dengue, West Nile and yellow fever viruses. Of these 110 genes, four genes allowed a highly accurate classification of infected status. More recently, a new study of Ae. aegypti infected with Zika virus (ZIKV) was published, providing new data to investigate whether this “infection” gene set is also altered during a ZIKV infection. Our hypothesis is that the infection-associated signature may also serve as a proxy to classify the ZIKV infection in the vector. Raw data associated with the NCBI/BioProject were downloaded and re-analysed. A total of 18 paired-end replicates corresponding to three ZIKV-infected samples and three controls were included in this study. The nMDS technique with a logistic regression was used to obtain the probabilities of belonging to a given class. Thus, to compare both gene sets, we used the area under the curve and performed a comparison using the bootstrap method. Our meta-signature was able to separate the infected mosquitoes from the controls with good predictive power to classify the Zika-infected mosquitoes.

Ornamental bromeliads of Miami-Dade County, Florida are important breeding sites for Aedes aegypti (Diptera: Culicidae)

BACKGROUND

A major public health concern is the emergence and geographical spread of vector-borne diseases such as Zika and yellow fever. Ornamental bromeliads retaining water in their leaf axils represent potential breeding sites for mosquitoes. As the role of ornamental bromeliads in breeding Aedes aegypti in Miami-Dade County, Florida is unknown, we hypothesize that ornamental bromeliads are important breeding sites for Ae. aegypti. Our objective was to survey bromeliads in areas with high densities of adult Ae. aegypti, including those with 2016 local transmission of Zika virus.

METHODS

Ornamental bromeliads were surveyed for the presence of immature mosquitoes at 51 locations of Miami-Dade County, Florida. Bromeliads were sampled for the presence of immature stages of mosquitoes, their reservoirs were drained and screened for the presence of immature mosquitoes. Immature mosquitoes were stored in plastic containers and preserved in 70% ethanol until morphological identification. Biodiversity of species assemblages was assessed by Shannon's and Simpson's indices, and individual rarefaction curves and plots of cumulative abundance, Shannon's index and evenness profiles.

RESULTS

Ornamental bromeliads were present in all surveyed areas, yielding a total of 765 immature mosquitoes, comprising five taxonomic units: Ae. aegypti, Wyeomyia mitchellii, Wyeomyia vanduzeei, Culex quinquefasciatus and Culex biscaynensis. The biodiversity indices point to a low diversity scenario with a highly dominant species, Ae. aegypti.

DISCUSSION

Our findings suggest that ornamental bromeliads are contributing for the proliferation of Ae. aegypti in the County of Miami-Dade, which may indicate a shift in the paradigm of usage of bromeliads as breeding sites, highlighting that ornamental phytotelmata bromeliads are to be considered in future vector-control strategies to control Zika and other arboviruses.

What Do Germans Want to Know About Skin Cancer? A Nationwide Google Search Analysis From 2013 to 2017

Background

Experts worldwide agree that skin cancer is a global health issue, but only a few studies have reported on world populations’ interest in skin cancer. Internet search data can reflect the interest of a population in different topics and thereby identify what the population wants to know.

Objective

Our aim was to assess the interest of the German population in nonmelanoma skin cancer and melanoma.

Methods

Google AdWords Keyword Planner was used to identify search terms related to nonmelanoma skin cancer and melanoma in Germany from November 2013 to October 2017. The identified search terms were assessed descriptively using SPSS version 24.0. In addition, the search terms were qualitatively categorized.

Results

A total of 646 skin cancer-related search terms were identified with 19,849,230 Google searches in the period under review. The search terms with the highest search volume were “skin cancer” (n=2,388,500, 12.03%), “white skin cancer” (n=2,056,900, 10.36%), “basalioma” (n=907,000, 4.57%), and “melanoma” (n=717,800, 3.62%). The most searched localizations of nonmelanoma skin cancer were “nose” (n=93,370, 38.99%) and “face” (n=53,270, 22.24%), and the most searched of melanoma were “nails” (n=46,270, 70.61%) and “eye” (n=10,480, 15.99%). The skin cancer‒related category with the highest search volume was “forms of skin cancer” (n=10,162,540, 23.28%) followed by “skin alterations” (n=4,962,020, 11.36%).

Conclusions

Our study provides insight into terms and fields of interest related to skin cancer relevant to the German population. Furthermore, temporal trends and courses are shown. This information could aid in the development and implementation of effective and sustainable awareness campaigns by developing information sources targeted to the population’s broad interest or by implementing new Internet campaigns.

Yellow fever

The yellow fever (YF) virus is a Flavivirus, transmitted by Haemagogus, Sabethes or Aedes aegypti mosquitoes. The disease is endemic in forest areas in Africa and Latin America leading to epizootics in monkeys that constitute the reservoir of the disease. There are two forms of YF: sylvatic, transmitted accidentally when approaching the forests, and urban, which can be perpetuated by Aedes aegypti. In Brazil, the last case of urban YF occurred in 1942. Since then, there has been an expansion of transmission areas from the North and Midwest regions to the South and Southeast. In 2017, the country faced an important outbreak of the disease mainly in the states of Minas Gerais, Espírito Santo and Rio de Janeiro. In 2018, its reach extended from Minas Gerais toward São Paulo. Yellow fever has an incubation period of 3 to 6 days and sudden onset of symptoms with high fever, myalgia, headache, nausea/vomiting and increased transaminases. The disease ranges from asymptomatic to severe forms. The most serious forms occur in around 15% of those infected, with high lethality rates. These forms lead to renal, hepatic and neurological impairment, and bleeding episodes. Treatment of mild and moderate forms is symptomatic, while severe and malignant forms depend on intensive care. Prevention is achieved by administering the vaccine, which is an effective (immunogenicity at 90-98%) and safe (0.4 severe events per 100,000 doses) measure. In 2018, the first transplants in the world due to YF were performed. There is also an attempt to evaluate the use of active drugs against the virus in order to reduce disease severity.

Effects of desiccation stress on adult female longevity in Aedes aegypti and Ae. albopictus (Diptera: Culicidae): results of a systematic review and pooled survival analysis

Background

Transmission dynamics of mosquito-borne viruses such as dengue, Zika and chikungunya are affected by the longevity of the adult female mosquito. Environmental conditions influence the survival of adult female Aedes mosquitoes, the primary vectors of these viruses. While the association of temperature with Aedes mortality has been relatively well-explored, the role of humidity is less established. The current study’s goals were to compile knowledge of the influence of humidity on adult survival in the important vector species Aedes aegypti and Ae. albopictus, and to quantify this relationship while accounting for the modifying effect of temperature.

Methods

We performed a systematic literature review to identify studies reporting experimental results informing the relationships among temperature, humidity and adult survival in Ae. aegypti and Ae. albopictus. Using a novel simulation approach to harmonize disparate survival data, we conducted pooled survival analyses via stratified and mixed effects Cox regression to estimate temperature-dependent associations between humidity and mortality risk for these species across a broad range of temperatures and vapor pressure deficits.

Results

After screening 1517 articles, 17 studies (one in semi-field and 16 in laboratory settings) met inclusion criteria and collectively reported results for 192 survival experiments. We review and synthesize relevant findings from these studies. Our stratified model estimated a strong temperature-dependent association of humidity with mortality in both species, though associations were not significant for Ae. albopictus in the mixed effects model. Lowest mortality risks were estimated around 27.5 °C and 21.5 °C for Ae. aegypti and Ae. albopictus, respectively, and mortality increased non-linearly with decreasing humidity. Aedes aegypti had a survival advantage relative to Ae. albopictus in the stratified model under most conditions, but species differences were not significant in the mixed effects model.

Conclusions

Humidity is associated with mortality risk in adult female Ae. aegypti in controlled settings. Data are limited at low humidities, temperature extremes, and for Ae. albopictus, and further studies should be conducted to reduce model uncertainty in these contexts. Desiccation is likely an important factor in Aedes population dynamics and viral transmission in arid regions. Models of Aedes-borne virus transmission may be improved by more comprehensively representing humidity effects.

Electronic supplementary material

The online version of this article (10.1186/s13071-018-2808-6) contains supplementary material, which is available to authorized users.

Factors contributing to and strategies to combat emerging arboviruses

Less than half a century ago infectious diseases appeared to be destined to be extinguished via as a culmination of medical triumphs. As focus turned towards combating non-communicable diseases, emerging and re-emerging diseases (EIDs) have bloomed from those ashes. Five epidemic mosquito-borne arboviruses (Yellow Fever virus (YFV), Dengue virus, West Nile virus, Chikungunya virus, and Zika virus) have emerged in the recent past. Arboviruses are of the utmost importance with respect to EIDs due to intensive growth of globalisation, arthropod urban fitness/adaption, and environmental changes. We focus on recent outbreaks of the arthropod borne viruses (arboviruses) Zika virus and YFV. Factors contributing to the blossoming of EIDs (environmental, globalisation, and urbanisation) and combating strategies (surveillance, containment, and prevention) will be discussed. Specifically, Zika virus and YFV will be used in the context of these factors and strategies. YFV is discussed in detail as it pertains to these factors and strategies in the United States (US), 2017 Brazil Outbreak, 2016 Africa Outbreak, and global risk. Vigilance is needed to focus on, prevent, and control the current and next arbovirus EIDs.

The use of humanized mice for studies of viral pathogenesis and immunity

Humanized mice, that is, animals engrafted with human tissues and/or expressing human genes, have been instrumental in improving our understanding of the pathogenesis and immunological processes that define some of the most challenging human-tropic viruses. In particular, mice engrafted with components of a human immune system (HIS) offer unprecedented opportunities for mechanistic studies of human immune responses to infection. Here, we provide a brief overview of the current panel of HIS mouse models available and cite recent examples of how such humanized animals have been used to study immune responses and pathogenesis elicited by human-tropic viruses. Finally, we will outline some of the challenges that lay ahead and strategies to improve and refine humanized mice with the goal of more accurately recapitulating human immune responses to viral infection.

Multi-color fluorescent reporter dengue viruses with improved stability for analysis of a multi-virus infection

Reporter virus is a versatile tool to visualize and to analyze virus infections. However, for flaviviruses, it is difficult to maintain the inserted reporter genes on the viral genome, limiting its use in several studies that require homogeneous virus particles and several rounds of virus replication. Here, we showed that flanking inserted GFP genes on both sides with ribosome-skipping 2A sequences improved the stability and the consistency of their fluorescent signals for dengue-virus-serotype 2 (DENV2) reporter viruses. The reporter viruses can infect known susceptible mammalian cell lines and primary CD14+ human monocytes. This design can accommodate several fluorescent protein genes, enabling the generation of multi-color DENV2-16681 reporter viruses with comparable replication capabilities, as demonstrated by their abilities to maintain their fluorescent intensities during co-infections and to exclude superinfections regardless of the fluorescent tags. The reported design of multi-color DENV2 should be useful for high-throughput analyses, single-cell analysis, and characterizations of interference and superinfection in animal models.

Transgenic Mosquitoes - Fact or Fiction?

Technologies for controlling mosquito vectors based on genetic manipulation and the release of genetically modified mosquitoes (GMMs) are gaining ground. However, concrete epidemiological evidence of their effectiveness, sustainability, and impact on the environment and nontarget species is lacking; no reliable ecological evidence on the potential interactions among GMMs, target populations, and other mosquito species populations exists; and no GMM technology has yet been approved by the WHO Vector Control Advisory Group. Our opinion is that, although GMMs may be considered a promising control tool, more studies are needed to assess their true effectiveness, risks, and benefits. Overall, several lines of evidence must be provided before GMM-based control strategies can be used under the integrated vector management framework.

Revamping Mosquito-borne Disease Control to Tackle Future Threats

The global approach to mosquito-borne diseases (MBDs) is in need of critical re-evaluation. Although there have been dramatic reductions in malaria incidence since 2000, malaria elimination from high-transmission settings remains problematic. At the same time, arbovirus outbreaks have increased in their frequency and impact. The 2015-2016 Zika virus epidemic exposed the dire state of MBD control in many countries, calling for united global action. Despite international resolve to prevent future epidemics, current practices in MBD control are mostly reactive and of limited efficacy. In this Opinion article, we summarize the views of 25 international mosquito experts about the current state of MBD control and highlight the issues that must be addressed in order to tackle emerging threats on the horizon.

Existing and potential infection risk zones of yellow fever worldwide: a modelling analysis

Background

Yellow fever cases are under-reported and the exact distribution of the disease is unknown. An effective vaccine is available but more information is needed about which populations within risk zones should be targeted to implement interventions. Substantial outbreaks of yellow fever in Angola, Democratic Republic of the Congo, and Brazil, coupled with the global expansion of the range of its main urban vector, Aedes aegypti, suggest that yellow fever has the propensity to spread further internationally. The aim of this study was to estimate the disease's contemporary distribution and potential for spread into new areas to help inform optimal control and prevention strategies.

Methods

We assembled 1155 geographical records of yellow fever virus infection in people from 1970 to 2016. We used a Poisson point process boosted regression tree model that explicitly incorporated environmental and biological explanatory covariates, vaccination coverage, and spatial variability in disease reporting rates to predict the relative risk of apparent yellow fever virus infection at a 5 × 5 km resolution across all risk zones (47 countries across the Americas and Africa). We also used the fitted model to predict the receptivity of areas outside at-risk zones to the introduction or reintroduction of yellow fever transmission. By use of previously published estimates of annual national case numbers, we used the model to map subnational variation in incidence of yellow fever across at-risk countries and to estimate the number of cases averted by vaccination worldwide.

Findings

Substantial international and subnational spatial variation exists in relative risk and incidence of yellow fever as well as varied success of vaccination in reducing incidence in several high-risk regions, including Brazil, Cameroon, and Togo. Areas with the highest predicted average annual case numbers include large parts of Nigeria, the Democratic Republic of the Congo, and South Sudan, where vaccination coverage in 2016 was estimated to be substantially less than the recommended threshold to prevent outbreaks. Overall, we estimated that vaccination coverage levels achieved by 2016 avert between 94 336 and 118 500 cases of yellow fever annually within risk zones, on the basis of conservative and optimistic vaccination scenarios. The areas outside at-risk regions with predicted high receptivity to yellow fever transmission (eg, parts of Malaysia, Indonesia, and Thailand) were less extensive than the distribution of the main urban vector, A aegypti, with low receptivity to yellow fever transmission in southern China, where A aegypti is known to occur.

Interpretation

Our results provide the evidence base for targeting vaccination campaigns within risk zones, as well as emphasising their high effectiveness. Our study highlights areas where public health authorities should be most vigilant for potential spread or importation events.

Funding

Bill & Melinda Gates Foundation.

Yellow Fever Virus, but Not Zika Virus or Dengue Virus, Inhibits T-Cell Receptor-Mediated T-Cell Function by an RNA-Based Mechanism

The Flavivirus genus within the Flaviviridae family is comprised of many important human pathogens including yellow fever virus (YFV), dengue virus (DENV), and Zika virus (ZKV), all of which are global public health concerns. Although the related flaviviruses hepatitis C virus and human pegivirus (formerly named GBV-C) interfere with T-cell receptor (TCR) signaling by novel RNA and protein-based mechanisms, the effect of other flaviviruses on TCR signaling is unknown. Here, we studied the effect of YFV, DENV, and ZKV on TCR signaling. Both YFV and ZKV replicated in human T cells in vitro; however, only YFV inhibited TCR signaling. This effect was mediated at least in part by the YFV envelope (env) protein coding RNA. Deletion mutagenesis studies demonstrated that expression of a short, YFV env RNA motif (vsRNA) was required and sufficient to inhibit TCR signaling. Expression of this vsRNA and YFV infection of T cells reduced the expression of a Src-kinase regulatory phosphatase (PTPRE), while ZKV infection did not. YFV infection in mice resulted in impaired TCR signaling and PTPRE expression, with associated reduction in murine response to experimental ovalbumin vaccination. Together, these data suggest that viruses within the flavivirus genus inhibit TCR signaling in a species-dependent manner.

A review of selected Arboviruses during pregnancy

Arboviruses are emerging infectious diseases with the ability to expand geographically and rapidly affect large populations.

The recent epidemic caused by the Zika virus in the Americas and congenital Zika syndrome associated with maternal infection has called out attention to the importance of studying arboviruses during pregnancy.

This is a review on selected arboviruses infections during gestation, including Zika, Chikungunya, Dengue and Yellow Fever viruses. Issues such as historical overview, pathogenesis, transmission, clinical conditions, diagnosis, treatment and prevention are addressed.

Global yellow fever vaccination coverage from 1970 to 2016: an adjusted retrospective analysis

Background

Substantial outbreaks of yellow fever in Angola and Brazil in the past 2 years, combined with global shortages in vaccine stockpiles, highlight a pressing need to assess present control strategies. The aims of this study were to estimate global yellow fever vaccination coverage from 1970 through to 2016 at high spatial resolution and to calculate the number of individuals still requiring vaccination to reach population coverage thresholds for outbreak prevention.

Methods

For this adjusted retrospective analysis, we compiled data from a range of sources (eg, WHO reports and health-service-provider registeries) reporting on yellow fever vaccination activities between May 1, 1939, and Oct 29, 2016. To account for uncertainty in how vaccine campaigns were targeted, we calculated three population coverage values to encompass alternative scenarios. We combined these data with demographic information and tracked vaccination coverage through time to estimate the proportion of the population who had ever received a yellow fever vaccine for each second level administrative division across countries at risk of yellow fever virus transmission from 1970 to 2016.

Findings

Overall, substantial increases in vaccine coverage have occurred since 1970, but notable gaps still exist in contemporary coverage within yellow fever risk zones. We estimate that between 393·7 million and 472·9 million people still require vaccination in areas at risk of yellow fever virus transmission to achieve the 80% population coverage threshold recommended by WHO; this represents between 43% and 52% of the population within yellow fever risk zones, compared with between 66% and 76% of the population who would have required vaccination in 1970.

Interpretation

Our results highlight important gaps in yellow fever vaccination coverage, can contribute to improved quantification of outbreak risk, and help to guide planning of future vaccination efforts and emergency stockpiling.

Funding

The Rhodes Trust, Bill & Melinda Gates Foundation, the Wellcome Trust, the National Library of Medicine of the National Institutes of Health, the European Union's Horizon 2020 research and innovation programme.

Multiple introductions of the dengue vector, Aedes aegypti, into California

The yellow fever mosquito Aedes aegypti inhabits much of the tropical and subtropical world and is a primary vector of dengue, Zika, and chikungunya viruses. Breeding populations of A. aegypti were first reported in California (CA) in 2013. Initial genetic analyses using 12 microsatellites on collections from Northern CA in 2013 indicated the South Central US region as the likely source of the introduction. We expanded genetic analyses of CA A. aegypti by: (a) examining additional Northern CA samples and including samples from Southern CA, (b) including more southern US populations for comparison, and (c) genotyping a subset of samples at 15,698 SNPs. Major results are: (1) Northern and Southern CA populations are distinct. (2) Northern populations are more genetically diverse than Southern CA populations. (3) Northern and Southern CA groups were likely founded by two independent introductions which came from the South Central US and Southwest US/northern Mexico regions respectively. (4) Our genetic data suggest that the founding events giving rise to the Northern CA and Southern CA populations likely occurred before the populations were first recognized in 2013 and 2014, respectively. (5) A Northern CA population analyzed at multiple time-points (two years apart) is genetically stable, consistent with permanent in situ breeding. These results expand previous work on the origin of California A. aegypti with the novel finding that this species entered California on multiple occasions, likely some years before its initial detection. This work has implications for mosquito surveillance and vector control activities not only in California but also in other regions where the distribution of this invasive mosquito is expanding.

Infectious diseases transmitted by Aedes aegypti, also known as the yellow fever mosquito, are of growing concern in tropical and subtropical regions. Dengue and Zika incidences are increasing, and no vaccines are currently available. Here we investigate the origin of California A. aegypti and find that this mosquito likely entered California on multiple occasions, at least once from the South Central US region and once from the Southwest US/northern MX region. The evidence suggests that the first invasion event likely occurred some years before its initial detection in 2013, despite California’s extensive and active surveillance program, implying that this invasive mosquito can go undetected. Understanding the invasion dynamics, gene flow, and population structure of A. aegypti can improve the monitoring of mosquitoes and prevent outbreaks of vector-borne disease.

Progress and Works in Progress: Update on Flavivirus Vaccine Development

Most areas of the globe are endemic for at least one flavivirus, putting billions at risk for infection. This diverse group of viral pathogens causes a range of manifestations in humans from asymptomatic infection to hemorrhagic fever to encephalitis to birth defects and even death. Many flaviviruses are transmitted by mosquitos and have expanded in geographic distribution in recent years, with dengue virus being the most prevalent, infecting approximately 400 million people each year. The explosive emergence of Zika virus in Latin America in 2014 refocused international attention on this medically important group of viruses. Meanwhile, yellow fever has caused major outbreaks in Africa and South America since 2015 despite a reliable vaccine. There is no vaccine for Zika yet, and the only licensed dengue vaccine performs suboptimally in certain contexts. Further lessons are found when considering the experience with Japanese encephalitis virus, West Nile virus, and tickborne encephalitis virus, all of which now have protective vaccination in human or veterinary populations. Thus, vaccination is a mainstay of public health strategy for combating flavivirus infections; however, numerous challenges exist along the path from development to delivery of a tolerable and effective vaccine. Nevertheless, intensification of investment and effort in this area holds great promise for significantly reducing the global burden of disease attributable to flavivirus infection.

Yellow fever in a traveller returning from Suriname to the Netherlands, March 2017

A Dutch traveller returning from Suriname in early March 2017, presented with fever and severe acute liver injury. Yellow fever was diagnosed by (q)RT-PCR and sequencing. During hospital stay, the patient’s condition deteriorated and she developed hepatic encephalopathy requiring transfer to the intensive care. Although yellow fever has not been reported in the last four decades in Suriname, vaccination is recommended by the World Health Organization for visitors to this country.

Establishment and cryptic transmission of Zika virus in Brazil and the Americas

Transmission of Zika virus (ZIKV) in the Americas was first confirmed in May 2015 in northeast Brazil. Brazil has had the highest number of reported ZIKV cases worldwide (more than 200,000 by 24 December 2016) and the most cases associated with microcephaly and other birth defects (2,366 confirmed by 31 December 2016). Since the initial detection of ZIKV in Brazil, more than 45 countries in the Americas have reported local ZIKV transmission, with 24 of these reporting severe ZIKV-associated disease. However, the origin and epidemic history of ZIKV in Brazil and the Americas remain poorly understood, despite the value of this information for interpreting observed trends in reported microcephaly. Here we address this issue by generating 54 complete or partial ZIKV genomes, mostly from Brazil, and reporting data generated by a mobile genomics laboratory that travelled across northeast Brazil in 2016. One sequence represents the earliest confirmed ZIKV infection in Brazil. Analyses of viral genomes with ecological and epidemiological data yield an estimate that ZIKV was present in northeast Brazil by February 2014 and is likely to have disseminated from there, nationally and internationally, before the first detection of ZIKV in the Americas. Estimated dates for the international spread of ZIKV from Brazil indicate the duration of pre-detection cryptic transmission in recipient regions. The role of northeast Brazil in the establishment of ZIKV in the Americas is further supported by geographic analysis of ZIKV transmission potential and by estimates of the basic reproduction number of the virus.