A comparison of the diseases caused by Ross River virus and Barmah Forest virus

Risks for Ross River virus disease in tropical Australia

BACKGROUND

There are no analytical studies of individual risks for Ross River virus (RRV) disease. Therefore, we set out to determine individual risk and protective factors for RRV disease in a high incidence area and to assess the utility of the case-control design applied for this purpose to an arbovirus disease.

METHODS

We used a prospective matched case-control study of new community cases of RRV disease in the local government areas of Cairns, Mareeba, Douglas, and Atherton, in tropical Queensland, from January 1 to May 31, 1998.

RESULTS

Protective measures against mosquitoes reduced the risk for disease. Mosquito coils, repellents, and citronella candles each decreased risk by at least 2-fold, with a dose-response for the number of protective measures used. Light-coloured clothing decreased risk 3-fold. Camping increased the risk 8-fold.

CONCLUSIONS

These risks were substantial and statistically significant, and provide a basis for educational programs on individual protection against RRV disease in Australia. Our study demonstrates the utility of the case-control method for investigating arbovirus risks. Such a risk analysis has not been done before for RRV infection, and is infrequently reported for other arbovirus infections.

Clinical and pathologic aspects of arthritis due to Ross River virus and other alphaviruses

PURPOSE OF REVIEW

Arthritogenic alphaviruses are globally distributed mosquito-borne RNA viruses causing epidemics of polyarthritis/arthralgia, with disease emerging or reemerging and increasingly being reported in travelers. This article summarizes the current knowledge of these diseases, focusing on recent developments in the understanding of Ross River virus disease.

RECENT FINDINGS

Alphaviral arthritides have often been blamed for protracted chronic illnesses. However, validated quality-of-life questionnaires and exhaustive searches for differential diagnoses showed that Ross River virus disease, although severe at onset, progressively resolved over 3 to 6 months. Many patients did experience long-term disease lasting more than 12 months, but in nearly all cases this was due to other conditions, primarily unrelated rheumatic conditions or depression. There is no indication that alphaviral arthritides predispose to other conditions; thus, patients whose Ross River virus disease has actually resolved may be underdiagnosed for other conditions. Ross River virus polyarthritis probably arises from inflammation associated with productive viral infections in synovial macrophages, which persist despite neutralizing antibodies and antiviral cytokine responses. Persistence may be facilitated by downregulation of cytokine responses by virus-antibody complexes binding to Fc receptors and induction of interleukin-10. How virus escapes neutralizing antibodies remains unclear but may involve phagocytosis of apoptotic virus-infected cells and infection of the phagocyte via the phagosome.

SUMMARY

Diagnosis of alphaviral arthritides is complicated by nonspecific symptoms and the lack of commercial serodiagnostic kits, except for Ross River and Barmah Forest virus infections in Australia. Differential diagnoses should be actively pursued, especially if symptoms persist. Treatment with nonsteroidal anti-inflammatory drugs appears largely effective, with no evidence of long-term sequelae or relapse.

Barmah Forest viral exanthems

A series of five patients presented with eruptions beginning on the face. In each case the facial changes were characterized by urticated erythema with minimal epidermal change. The patients also demonstrated more widespread vesiculopapular, macular or purpuric eruptions. At presentation most patients were asymptomatic; however, several subsequently developed constitutional symptoms. Each of these patients was reactive for Barmah Forest virus immunoglobulin (Ig)M, and on repeat testing four were reactive for Barmah Forest virus IgG.

Ross River virus disease in Australia, 1886-1998, with analysis of risk factors associated with outbreaks

Ross River virus (RR) is a mosquito-borne arbovirus responsible for outbreaks of polyarthritic disease throughout Australia. To better understand human and environmental factors driving such events, 57 historical reports on RR outbreaks between 1896 and 1998 were examined collectively. The magnitude, regularity, seasonality, and locality of outbreaks were found to be wide ranging; however, analysis of climatic and tidal data highlighted that environmental conditions act differently in tropical, arid, and temperate regions. Overall, rainfall seems to be the single most important risk factor, with over 90% of major outbreak locations receiving higher than average rainfall in preceding months. Many temperatures were close to average, particularly in tropical populations; however, in arid regions, below average maximum temperatures predominated, and in southeast temperate regions, above average minimum temperatures predominated. High spring tides preceded coastal outbreaks, both in the presence and absence of rainfall, and the relationship between rainfall and the Southern Oscillation Index and La Niña episodes suggest they may be useful predictive tools, but only in southeast temperate regions. Such heterogeneity predisposing outbreaks supports the notion that there are different RR epidemiologies throughout Australia but also suggests that generic parameters for the prediction and control of outbreaks are of limited use at a local level.

Ross River virus disease in tropical Queensland: evolution of rheumatic manifestations in an inception cohort followed for six months

OBJECTIVE

To describe the natural history of rheumatic manifestations of Ross River virus (RRV) disease.

DESIGN

Prospective longitudinal clinical review.

SETTING

North Queensland local government areas of Cairns, Douglas, Mareeba and Atherton during January to May 1998.

PARTICIPANTS

General practice patients diagnosed with RRV disease on the basis of symptoms and a positive RRV IgM result.

MAIN OUTCOME MEASURES

Rheumatic symptoms and signs assessed as soon as possible after disease onset and on two subsequent occasions (up to 6.5 months after onset).

RESULTS

57 patients were recruited, 47 of whom were reviewed three times (at means of 1.1, 2.4 and 3.6 months after disease onset). Results are reported for these 47: 46 (98%) complained of joint pain at first review, with the ankles, wrists, fingers, knees and metacarpophalangeal joints (II-IV) most commonly involved. Prevalence of joint pain decreased progressively on second and third reviews, both overall (92% and 68% of patients, respectively), and in the five joints most commonly affected. The prevalence of other common rheumatic symptoms and signs, and use of non-steroidal anti-inflammatory drugs, also progressively declined over the three reviews.

CONCLUSIONS

Earlier studies may have overestimated the prevalence and duration of symptoms in RRV disease. Progressive resolution over 3-6 months appears usual.

Natural history of Ross River virus-induced epidemic polyarthritis

OBJECTIVE

To describe the natural history, treatment and cost of Ross River virus-induced epidemic polyarthritis (RRV disease).

DESIGN

Questionnaire-based longitudinal prospective study.

PARTICIPANTS AND SETTING

Patients in the greater Brisbane area, Queensland, diagnosed with RRV disease by their general practitioners based on clinical symptoms and paired serological tests between November 1997 and April 1999.

MAIN OUTCOME MEASURES

Scores on two validated quality-of-life questionnaires (Clinical Health Assessment Questionnaire and Medical Outcomes Study Short Form 36) were obtained soon after diagnosis and one, two, three, six and 12 months thereafter. Scores were compared between patients diagnosed with RRV disease alone and those with RRV disease plus other conditions.

RESULTS

67 patients were enrolled. Most patients with RRV disease alone had severe acute symptoms, but followed a consistent path to recovery within three to six months. Other conditions, often chronic rheumatic diseases or depression, were identified in half the cohort; their quality-of-life scores suggested stable chronic illness between six and 12 months after diagnosis. Non-steroidal anti-inflammatory drugs (NSAIDs) were taken by 58% of patients (average use, 7.6 weeks; range, 2-22 weeks). Time off work averaged 1.9 days, and direct cost to the community was estimated as 1018 Australian dollars per patient.

CONCLUSIONS

Symptom duration and frequency of long-term symptoms may have been overestimated by previous studies of RRV disease. Disease persisting six to 12 months after RRV diagnosis was largely attributable to other conditions, highlighting the need to seek other diagnoses in RRV patients with persistent symptoms.

Persistent Ross River virus infection of murine macrophages: an in vitro model for the study of viral relapse and immune modulation during long-term infection

A clinical feature of Ross River virus disease (RRVD) is the periodic relapse of symptoms months after the initial onset of disease. The underlying mechanisms responsible for this relapse have not been determined. In a long-term (148 days) in vitro study of persistently infected murine macrophages we established that RRV infection periodically fell to undetectable biological levels that required genetic detection. However, the virus concentration spontaneously relapsed to biologically detectable levels that corresponded with enhanced viral mRNA expression, cellular detachment, and cytopathic effect. By altering the cell culture conditions we found that relapse could also be induced. We propose that the periodic relapse of symptoms in RRVD may be associated with spontaneous or stress-induced increases in RRV within persistently infected macrophages. This study also established that RRV enhanced macrophage phagocytic activity and dysregulated the immunoregulatory molecules CD80, IFN-gamma, and TNF-alpha that may facilitate persistence of RRV and avoidance of immune responses.

The risk of Ross River and Barmah Forest virus disease in Queensland: implications for New Zealand

OBJECTIVES

To describe the incidence of Ross River (RR) and Barmah Forest (BF) virus disease in Queensland and determine the risk of importation of RR virus from Queensland into New Zealand (NZ) via viraemic travellers.

METHODS

Based on routine RR and BF virus notification data of seven major urban tropical and subtropical Queensland populations, incidence rates adjusted for age, sex, season and a baseline level of immunity were used to examine the annual and seasonal risk of disease in the specific populations and selected subgroups. The risk for NZ was determined by estimating the number of infections among major visitor groups travelling from Queensland to NZ, using seroconversion rates.

RESULTS

In Queensland, annual rates of RR and BF virus disease ranged between 31.5-288.3 and 3.4-37.4/100,000 person years respectively and increased to between 48.4-423.5 and 3.8-40.4/100,000 person years at risk when adjusted for immunity. Our estimates indicate that more than 100 viraemic travellers may enter NZ from Queensland each year. Estimates were greatest among New Zealanders returning home.

CONCLUSIONS AND IMPLICATIONS

Usefulness of notification data could be maximised by presenting more detailed information to the local governments responsible for the control and public health awareness of these pathogens. Given the high number of viraemic persons entering NZ, the abundance of possums and the emergence of Oc. camptorhynchus, transmission of RR virus within NZ is probable. Health authorities should prepare for a virgin soil epidemic of RR virus by initiating serological and clinical surveillance in key areas, enhance public and professional awareness and elevate national resources necessary to invoke emergency vector control and case management.

Ross River virus: ecology and distribution

Ross River virus is the most common mosquito-borne pathogen in Australia, and approximately 5000 human cases are reported annually. The infection is not fatal, but there is considerable morbidity associated with a debilitating polyarthritis that is the major symptom. The virus is annually active in most regions of Australia, but exists as strains that vary in virulence. Native macropods are thought to be the natural vertebrate hosts, although horses and humans may be involved during epidemic activity, and vertical transmission of the virus occurs in mosquitoes. Different mosquito species are involved as vectors in various regions and in different seasonal and environmental conditions. In coastal areas the saltmarsh mosquitoes Aedes camptorhynchus and Ae. vigilax are the most important vectors in southern and northern regions, respectively, whereas in inland areas Culex annulirostris is the most important vector, although various Aedes species can be involved depending on region and conditions, and the epidemiology of the disease and vector control imperatives vary with circumstance concomitantly.

Ross River virus transmission, infection, and disease: a cross-disciplinary review

Ross River virus (RRV) is a fascinating, important arbovirus that is endemic and enzootic in Australia and Papua New Guinea and was epidemic in the South Pacific in 1979 and 1980. Infection with RRV may cause disease in humans, typically presenting as peripheral polyarthralgia or arthritis, sometimes with fever and rash. RRV disease notifications in Australia average 5,000 per year. The first well-described outbreak occurred in 1928. During World War II there were more outbreaks, and the name epidemic polyarthritis was applied. During a 1956 outbreak, epidemic polyarthritis was linked serologically to a group A arbovirus (Alphavirus). The virus was subsequently isolated from Aedes vigilax mosquitoes in 1963 and then from epidemic polyarthritis patients. We review the literature on the evolutionary biology of RRV, immune response to infection, pathogenesis, serologic diagnosis, disease manifestations, the extraordinary variety of vertebrate hosts, mosquito vectors, and transmission cycles, antibody prevalence, epidemiology of asymptomatic and symptomatic human infection, infection risks, and public health impact. RRV arthritis is due to joint infection, and treatment is currently based on empirical anti-inflammatory regimens. Further research on pathogenesis may improve understanding of the natural history of this disease and lead to new treatment strategies. The burden of morbidity is considerable, and the virus could spread to other countries. To justify and design preventive programs, we need accurate data on economic costs and better understanding of transmission and behavioral and environmental risks.

Emerging viral diseases of Southeast Asia and the Western Pacific

Over the past 6 years, a number of zoonotic and vectorborne viral diseases have emerged in Southeast Asia and the Western Pacific. Vectorborne disease agents discussed in this article include Japanese encephalitis, Barmah Forest, Ross River, and Chikungunya viruses. However, most emerging viruses have been zoonotic, with fruit bats, including flying fox species as the probable wildlife hosts, and these will be discussed as well. The first of these disease agents to emerge was Hendra virus, formerly called equine morbillivirus. This was followed by outbreaks caused by a rabies-related virus, Australian bat lyssavirus, and a virus associated with porcine stillbirths and malformations, Menangle virus. Nipah virus caused an outbreak of fatal pneumonia in pigs and encephalitis in humans in the Malay Peninsula. Most recently, Tioman virus has been isolated from flying foxes, but it has not yet been associated with animal or human disease. Of nonzoonotic viruses, the most important regionally have been enterovirus 71 and HIV.

Arboviruses associated with human disease in Australia

Mosquito-borne arboviruses are an important public health issue in Australia. The alphaviruses Ross River and Barmah Forest virus are widespread and active annually, and cause debilitating polyarthritis. The flaviviruses Murray Valley encephalitis, Kunjin and Japanese encephalitis virus are restricted in distribution and activity but may cause life-threatening illness, and dengue viruses are active in some areas.

Vector competence of Aedes aegypti, Culex sitiens, Culex annulirostris, and Culex quinquefasciatus (Diptera: Culicidae) for Barmah Forest virus

Aedes aegypti (L.), Culex sitiens Weidemann, Culex annulirostris Skuse, and Culex quinquefasciatus Say mosquitoes colonized at the Queensland Institute of Medical Research, Brisbane Australia, were fed on blood containing Barmah Forest virus (BF). Only Cx. annulirostris was susceptible to infection, with a median cell culture infectious dose (CCID50) of 10(3.36) per mosquito. Ae. aegypti and Cx. quinquefasciatus were infected experimentally, but at rates of < 9%. Cx. sitiens did not become infected. Infection rates for Cx. annulirostris fed 10(3.5) CCID50 of virus per mosquito, varied from 9 to 50% between 2 and 13 d after infection. Virus transmission to suckling mice by Cx. annulirostris occurred from 2 d after infection. Transmission of BF virus by Cx. annulirostris was 10% at 2 d after infection and did not exceed 8% thereafter. Although Cx. annulirostris may be infected and is able to transmit BF virus to suckling mice, it is nonetheless a relatively inefficient vector of the virus.

Vector competence of Aedes notoscriptus (Diptera: Culicidae) for Barmah Forest virus and of this species and Aedes aegypti (Diptera: Culicidae) for dengue 1-4 viruses in Queensland, Australia

Aedes notoscriptus (Skuse) mosquitoes colonized from Brisbane, Queensland, Australia, were fed on blood suspensions containing either Barmah Forest (BF) virus, dengue virus type 1 (DEN-1), dengue virus type 2 (DEN-2), dengue virus type 3 (DEN-3), or dengue virus type 4 (DEN-4). Ae. notoscriptus was shown to be moderately susceptible to oral infection with BF virus, ID50 = 10(3.3) CCID50 per mosquito, with titers in infected mosquitoes peaking 10 d after infection. BF virus transmission occurred between days 5 and 12, with an average rate of 45% (range, 40-50%). For DEN 1-4, Ae. notoscriptus showed low level susceptibility to oral infection, with maximum head and thorax squash infection rates of 8, 5, 13, and 3%, respectively. Rates of infection were notably higher in a north Queensland strain of Aedes aegypti (L.) used as a positive control, with maximum thorax squash infection rates of 58, 68, 78, and 60% for DEN 1-4, respectively. On the basis of these data, it is concluded that Ae. notoscriptus could act as an efficient vector of BF in urban environments, but it is unlikely to be an important vector of DEN.