West Nile encephalitis epidemic in southeastern Romania

Immunogenicity and protective efficacy of a recombinant subunit West Nile virus vaccine in rhesus monkeys

The immunogenicity and protective efficacy of a recombinant subunit West Nile virus (WNV) vaccine was evaluated in rhesus macaques (Macaca mulatta). The vaccine consisted of a recombinant envelope (E) protein truncated at the C-terminal end, resulting in a polypeptide containing 80% of the N-terminal amino acids of the native WNV protein (WN-80E), mixed with an adjuvant (GPI-0100). WN-80E was produced in a Drosophila melanogaster expression system with high yield and purified by immunoaffinity chromatography using a monoclonal antibody specific for flavivirus E proteins. Groups of monkeys were vaccinated with formulations containing 1 or 25 microg of WN-80E antigen, and both humoral and cellular immunity were assessed after vaccination. The results demonstrated potent antibody responses to vaccination, as determined by both enzyme-linked immunosorbent assay and virus-neutralizing antibody assays. All vaccinated animals responded favorably, and there was little difference in response between animals immunized with 1 or 25 microg of WN-80E. Cellular immunity was determined by lymphocyte proliferation and cytokine production assays using peripheral blood mononuclear cells from vaccinated animals stimulated in vitro with WN-80E. Cell-mediated immune responses varied from animal to animal within each group. About half of the animals responded with lymphoproliferation, cytokine production, or both. Again, there was little difference in response between animals immunized with a 1- or 25-microg dose of WN-80E in the vaccine formulations. In a separate experiment, groups of monkeys were immunized with the WN-80E/GPI-0100 vaccine or an adjuvant-only control formulation. Animals were then challenged by inoculation of wild-type WNV, and the level of viremia in each animal was monitored daily for 10 days. The results showed that whereas all animals in the control group had detectable viremia for at least 3 days after challenge, all of the vaccinated animals were negative on all days after challenge. Thus, the WN-80E vaccine was 100% efficacious in protecting monkeys against infection with WNV.

Overview of emerging arboviruses

Numerous arboviral outbreaks during the past decade have demonstrated that arthropod-borne pathogens continue to be significant public and animal health threats. These outbreaks have occurred globally and have not been limited to tropical or developing countries, as people and goods can be moved anywhere in the world within days. Several examples of recent outbreaks have been described, including how they were identified, tracked and the resulting outcomes from these events. Fortunately, scientific research, including advances in rapid detection of this diverse group of pathogens, has also been progressing. While arboviruses are likely to continually emerge and re-emerge, improved scientific technologies and approaches will hopefully make each future epidemic less likely to occur.

Changing patterns of West Nile virus transmission: altered vector competence and host susceptibility

West Nile virus (WNV) is a flavivirus (Flaviviridae) transmitted between Culex spp. mosquitoes and avian hosts. The virus has dramatically expanded its geographic range in the past ten years. Increases in global commerce, climate change, ecological factors and the emergence of novel viral genotypes likely play significant roles in the emergence of this virus; however, the exact mechanism and relative importance of each is uncertain. Previously WNV was primarily associated with febrile illness of children in endemic areas, but it was identified as a cause of neurological disease in humans in 1994. This modulation in disease presentation could be the result of the emergence of a more virulent genotype as well as the progression of the virus into areas in which the age structure of immunologically naïve individuals makes them more susceptible to severe neurological disease. Since its introduction to North America in 1999, a novel WNV genotype has been identified that has been demonstrated to disseminate more rapidly and with greater efficiency at elevated temperatures than the originally introduced strain, indicating the potential importance of temperature as a selective criteria for the emergence of WNV genotypes with increased vectorial capacity. Even prior to the North American introduction, a mutation associated with increased replication in avian hosts, identified to be under adaptive evolutionary pressure, has been identified, indicating that adaptation for increased replication within vertebrate hosts could play a role in increased transmission efficiency. Although stable in its evolutionary structure, WNV has demonstrated the capacity for rapidly adapting to both vertebrate hosts and invertebrate vectors and will likely continue to exploit novel ecological niches as it adapts to novel transmission foci.

[Up-to-date knowledge of West Nile virus infection]

VIRUS: West Nile virus is a single-stranded RNA virus of the family Flaviviridae, genus Flavivirus.

EPIDEMIOLOGY

West Nile virus is maintained in the cycle involving culicine mosquitoes and birds. Humans typically acquire West Nile infection through a bite from infected adult mosquito. Person to person transmission can occur through organ transplantation, blood and blood product transfusions, transplacentally and via breast milk. Human cases of West Nile infections were recorded in Africa, Israel, Russia, India, Pakistan. In Romania in 1996 West Nile fever occurred with hundreds of neurologic cases and 17 fatalities. First human cases in the United States were in New York City where 59 persons were infected and had fever, meningitis, encephalitis and flaccid paralysis. CLINICAL MANIFESTATION: Most human cases are asymptomatic. The majority of symptomatic patients have a self limited febrile illness. Fatigue, nausea, vomiting, eye pain, headache, myalgias, artralgias, lymphadenopathy and rash are common complaints. Less than 1% of all infected persons develop more severe neurologic illness including meningitis, encefalitis and flaccid paralysis.

LABORATORY DIAGNOSIS

Diagnosis of West Nile virus infection is based on serologic testing, isolation of virus from patient samples and detection of viral antigen or viral genom. ELISA test and indirect immunofluorescence assay are used for detecting IgM and IgG antibodies in serum and cerebrospinal fluid.

TREATMENT

In vitro studies have suggested that ribavirin and interferon alfa-2b may be useful in the treatment of West Nile virus disease.

PREVENTION

The most important measures are mosquito control program and personal protective measures.

Seroprevalence of west nile virus in ghana

The epidemiology of West Nile virus (WNV) in Ghana, sub-Saharan Africa, and its relevance to transfusion were newly assessed. A total of 1324 plasma samples from five Ghanaian populations, including 529 children (<6 y old, pre-transfusion) and 795 adults (236 blood donors, 226 HIV-infected or non-infected pregnant women, 203 HIV symptomatic patients, and 130 AIDS patients) were screened for WNV RNA. No WNV RNA was detected, but 4.8% (13/271) and 27.9% (127/455) carried specific IgG in children and adults, respectively, and 2.4% (4/167) of the children had IgM. The prevalence of IgG antibody to WNV increased progressively and peaked around 30% between ages 1 and 30 y, then stabilized. The absence of viremia in four WNV IgM-positive children, and of reactivation in HIV-infected patients suggests that once host immunity is established, it appears to be robust. In addition, there were no clinical reports of WNV infection in the hospital in Kumasi, Ghana, suggesting that WNV epidemiology in Ghana differs from that seen in the U.S. Most infections occur early in life, and as the window for infection is quite short, the risk of transmission by transfusion appears to be low, and the risk of pathogenicity in immunocompetent recipients appears to be limited in an endemic area such as Ghana.

Self-reported protective behaviour against West Nile Virus among pregnant women in Toronto

OBJECTIVE

West Nile virus (WNV) is an emerging infection that can lead to substantial morbidity and mortality. Although data are limited with respect to the risk to the fetus and neonate, this risk is not inconsequential. Methods to reduce the risk of mosquito bites and WNV transmission are simple, economical, and effective in the non-pregnant population. The objective of this descriptive cross-sectional study was to assess adherence to protective behaviours against WNV in pregnant women and to determine predictors for such adherence.

METHODS

A questionnaire was administered to all consenting pregnant women at two Toronto university hospitals.

RESULTS

The majority of women reported practising behaviours that reduce the risk of mosquito bites and potentially of WNV infection. In this survey, between 40% and 80% of pregnant women avoided the outdoors, avoided areas with mosquitoes, and reported practising two or more personal protection behaviours. However, only 33% of pregnant women reported wearing mosquito repellent, with the majority expressing concern about the safety of repellent use during pregnancy. The majority of pregnant women cited the media or the Internet as a source of their knowledge about WNV; only 12% reported their physician as a source of such knowledge.

CONCLUSION

The majority of pregnant women are aware of WNV and practise protective behaviours that reduce the risk of transmission. However, they have unjustified fetal safety concerns about the use of mosquito repellent and are thus less likely to use it.

Serological evidence of USUTU virus occurrence in north-eastern Italy

In the recent years, USUTU virus (USUV), a flavivirus of the Japanese encephalitis virus complex, has been reported in Central Europe. As part of a systematic surveillance programme to monitor possible entrance and/or circulation of vector-borne viruses, since 2001, sentinel-chicken flocks were placed throughout the Italian territory nearby areas considered at risk of virus introduction. They have been periodically checked for the presence of antibodies against flaviviruses by indirect ELISA, plaque reduction neutralization test for USUTU, West Nile and tick-borne encephalitis viruses. In July 2007, a sentinel chicken in a flock of 20 animals located within the Ravenna province seroconverted to USUV reaching neutralizing titres up to 1:5120. A second chicken seroconverted to the same virus 2 months later. Although no virus was rescued from these animals and from wild or farm birds sampled in the area, these results still provided evidence of the circulation of USUV in north-eastern Italy.

Global biosecurity in a complex, dynamic world

Biosecurity is emerging as a major global health priority for which innovative and unprecedented solutions are needed. Biosecurity is a challenging biocomplexity problem involving multifaceted processes such as interactions between humans and nonhuman biota, anthropogenic environmental and ecological factors, and socioeconomic and political pressures. Key to an effective biosecurity strategy will be fundamental understanding of evolutionary, anthropogenic and environmental driving forces at play in transmission and perpetuation of infectious diseases. Biosecurity solutions will depend on increased support of basic biomedical research and public education, enhanced healthcare preparedness, alternative strategies for ensuringsafety, and improved interagency cooperation regarding global health policy. © 2008 Wiley Periodicals, Inc. Complexity, 2008.

Outbreak of Chikungunya fever in Mayotte, Comoros archipelago, 2005-2006

In 2005-2006, a large outbreak of Chikungunya (CHIK) fever occurred on the western Indian Ocean Islands. In Mayotte, concurrent with an enhanced passive case notification system, we carried out two surveys. A seroprevalence survey designed to document recent CHIK infection was conducted on serum samples collected from pregnant women in October 2005 (n=316) and in March-April 2006 (n=629). A cross-sectional clinical community survey carried out from 2 to 10 May 2006 among 2235 individuals was designed to determine the cumulative incidence of presumptive CHIK fever cases. The seroprevalence of recent infection among pregnant women was 1.6% in October 2005 and rose to 26% in April 2006. The clinical community survey showed that nearly 26% of respondents had experienced presumptive CHIK fever between January and May 2006. Extrapolated to the overall population of Mayotte, these figures lead to an estimated attack rate of 249.5 cases per 1000 population as of early May 2006. Nine patients with the maternofetal form and six subjects with the severe form were recorded. This first emergence of CHIK fever in Mayotte lead to a very large outbreak. Efforts to strengthen surveillance and prevention of arbovirus infection are needed at country and regional levels.

Transmission dynamics and changing epidemiology of West Nile virus

West Nile virus (WNV) is a flavivirus that is maintained in a bird-mosquito transmission cycle. Humans, horses and other non-avian vertebrates are usually incidental hosts, but evidence is accumulating that this might not always be the case. Historically, WNV has been associated with asymptomatic infections and sporadic disease outbreaks in humans and horses in Africa, Europe, Asia and Australia. However, since 1994, the virus has caused frequent outbreaks of severe neuroinvasive disease in humans and horses in Europe and the Mediterranean Basin. In 1999, WNV underwent a dramatic expansion of its geographic range, and was reported for the first time in the Western Hemisphere during an outbreak of human and equine encephalitis in New York City. The outbreak was accompanied by extensive and unprecedented avian mortality. Since then, WNV has dispersed across the Western Hemisphere and is now found throughout the USA, Canada, Mexico and the Caribbean, and parts of Central and South America. WNV has been responsible for >27,000 human cases, >25,000 equine cases and hundreds of thousands of avian deaths in the USA but, surprisingly, there have been only sparse reports of WNV disease in vertebrates in the Caribbean and Latin America. This review summarizes our current understanding of WNV with particular emphasis on its transmission dynamics and changing epidemiology.

Influence of warming tendency on Culex pipiens population abundance and on the probability of West Nile fever outbreaks (Israeli Case Study: 2001-2005)

Climate change and West Nile fever (WNV) are both subjects of global importance. Many mosquitoes and the diseases they carry, including West Nile virus (WNV), are sensitive to temperature increase. The current study analyzes the lag correlations between weather conditions (especially air temperature) and 1) Culex pipiens mosquito population abundance, and 2) WNF frequency in humans, between 2001 and 2005 in Israel. These 5 years follow a long period with a documented tendency for temperature increase in the hot season in the country. Monthly anomalies of minimum and maximum temperatures, relative seasonal rainfall contribution, mosquito samplings (hazard level), and WNF cases (hospital admission dates and patients' addresses) were analyzed. Logistic regression was calculated between the climatic data and the mosquito samples, as Spearman correlations and Pearson cross-correlations were calculated between daily temperature values (or daily precipitation amounts) and the hospital admission dates. It was found that the disease appearance reflects the population distribution, while the risk tends to escalate around the metropolis characterized by an urban heat island. Positive anomalies of the temperature during the study period appear to have facilitated the mosquito abundance and, consequently, the disease emergence in humans. An important finding is the potential influence of extreme heat in the early spring on the vector population increase and on the disease's appearance weeks later. Awareness of such situations at the beginning of the spring may help authorities to reduce the disease risk before it becomes a real danger.

Vero cell-derived inactivated West Nile (WN) vaccine induces protective immunity against lethal WN virus infection in mice and shows a facilitated neutralizing antibody response in mice previously immunized with Japanese encephalitis vaccine

A novel Vero cell-derived inactivated WN vaccine (WN-VAX) was prepared from virus strain NY99-35262. Two immunizations with WN-VAX induced high levels of neutralizing antibody to WN virus. All immunized mice were protected against challenge with a lethal dose of WN virus. No WN viremia was detected, and the level of WN virus-neutralizing antibody increased rapidly. WN-VAX was then examined for immunogenicity in mice previously immunized with Japanese encephalitis vaccine (JE-VAX). Immunization with WN-VAX induced WN virus-neutralizing antibody in all mice previously immunized with JE-VAX but in only half of the control mice at 10 weeks. These results indicate that WN-VAX induced complete protective immunity against lethal WN infection and that the WN-VAX-induced antibody response is facilitated in JE-VAX-immunized mice. This WN-VAX is thus a candidate WN vaccine for humans.

Transmission of tropical and geographically restricted infections during solid-organ transplantation

In recent years, the increasing number of donors from different regions of the world is providing a new challenge for the management and selection of suitable donors. This is a worldwide problem in most countries with transplantation programs, especially due to the increase in immigration and international travel. This paper elaborates recommendations regarding the selection criteria for donors from foreign countries who could potentially transmit tropical or geographically restricted infections to solid-organ transplant recipients. For this purpose, an extensive review of the medical literature focusing on viral, fungal, and parasitic infections that could be transmitted during transplantation from donors who have lived or traveled in countries where these infections are endemic has been performed, with special emphasis on tropical and imported infections. The review also includes cases described in the literature as well as risks of transmission during transplantation, microbiological tests available, and recommendations for each infection. A table listing different infectious agents with their geographic distributions and specific recommendations is included.

The molecular basis of antibody protection against West Nile virus

West Nile virus (WNV) infection of mosquitoes, birds, and vertebrates continues to spread in the Western Hemisphere. In humans, WNV infects the central nervous system and causes severe disease, primarily in the immunocompromised and elderly. In this review we discuss the mechanisms by which antibody controls WNV infection. Recent virologic, immunologic, and structural experiments have enhanced our understanding on how antibodies neutralize WNV and protect against disease. These advances have significant implications for the development of novel antibody-based therapies and targeted vaccines.

A global perspective on the epidemiology of West Nile virus

West Nile virus (WNV) (Flavivirus: Flaviviridae) is the most widespread arbovirus in the world. A significant range expansion occurred beginning in 1999 when the virus was introduced into New York City. This review highlights recent research into WNV epizootiology and epidemiology, including recent advances in understanding of the host-virus interaction at the molecular, organismal, and ecological levels. Vector control strategies, vaccines, and antivirals, which now must be considered on a global scale, are also discussed.

Persistent infections of mammals and mammalian cell cultures with West Nile virus

Before 1990, West Nile virus (WNV) was considered to be one of many arthropod-borne viruses that caused mild febrile illness in man. However, in the 1990s, the virus was associated with severe CNS disease that produced mortality in horses and man in Europe. In 1999, WNV was identified as the etiologic agent of an outbreak of human and avian encephalitis in New York City (NY, USA). Like many other Flaviviridae family members, WNV is generally considered to cause acute infections, however, persistent WNV infections have been observed in laboratory-infected animals and in human patients. These persistent infections could be facilitated by changes to the viral genome that allow the virus to evade detection by the host cell, a property that has been studied in cell culture. This review highlights our current knowledge of persistent WNV infections in vitro and in vivo, and speculates on how persistence could influence virus transmission.

Electroencephalographic characteristics of patients infected with west nile virus

SUMMARY

: The EEG is helpful in the evaluation of patients with altered mental status and can provide clues for the underlying cause of certain entities. There are few descriptions of the EEG findings in patients with West Nile virus (WNV) infection. We describe the clinical presentation as well as the electroencephalographic findings in five patients with WNV encephalitis. Review of the records of all cases of WNV infection seen at the Mayo Clinic from 1999 to 2003, in which an EEG had been performed. Five patients with WNV encephalitis, in whom an EEG was performed, were found. All the patients had altered mental status and the EEG showed moderate to severe degrees of generalized slowing. Three of the patients had triphasic waves on the EEG. The patients did not have any metabolic disorder or electrolyte abnormalities that could account for these findings. EEG findings in WNV are consistent with an encephalopathic pattern and show varying degrees of generalized slow wave abnormalities and in some cases triphasic waves.

Antigen-specific cytotoxic T lymphocytes protect against lethal West Nile virus encephalitis

Infection with West Nile virus (WNV) causes fatal encephalitis in immunocompromised animals. Previous studies in mice have established that T cell protection is required for clearance of WNV infection from tissues and preventing viral persistence. The current study assessed whether specific WNV peptide epitopes could elicit a cytotoxic T lymphocyte (CTL) response capable of protecting against virus infection. Hidden Markov model analysis was used to identify WNV-encoded peptides that bound the MHC class I proteins K(b) or D(b). Of the 35 peptides predicted to bind MHC class I molecules, one immunodominant CTL recognition peptide was identified in each of the envelope and non-structural protein 4B genes. Addition of these but not control peptides to CD8(+) T cells from WNV-infected mice induced IFN-gamma production. CTL clones that were generated ex vivo lysed peptide-pulsed or WNV-infected target cells in an antigen-specific manner. Finally, adoptive transfer of a mixture of envelope- and non-structural protein 4B-specific CTL to recipient mice protected against lethal WNV challenge. Based on this, we conclude that CTL responses against immundominant WNV epitopes confer protective immunity and thus should be targets for inclusion in new vaccines.

The continuing spread of West Nile virus in the western hemisphere

West Nile virus (WNV) has historically been considered to be among the least virulent of the Japanese serogroup viruses of the family Flaviviridae, genus Flavivirus. However, recent epidemics associated with severe and fatal neuroinvasive disease have changed that perception. The emergence of a virus subtype with greater epidemic potential and virulence in the early 1990s facilitated the geographic expansion and westward spread of WNV; in 1999, it first appeared in the western hemisphere. Because of the broad host and vector range, the virus has become established in much of the region, and there is little chance that it will be eliminated. Transmission is difficult to predict and even more difficult to prevent and control. The cost-effectiveness of human WNV vaccines is uncertain. The building of laboratory diagnostic, epidemiologic, and vector-control capacity in WNV-enzootic countries is critical to the development of effective prevention and control strategies for WNV infection, as well as for other potential emerging vectorborne viral diseases.

Two Distinct Introductions of the West Nile Virus in Portugal Disclosed by Phylogenetic Analysis of Genomic Sequences

In this report, we describe genomic sequencing and analysis of different West Nile virus strains isolated from mosquitoes in the south of Portugal (Alentejo and Algarve) at two different time points (1971 and 2004, respectively). Phylogenetic analysis indicated different origins for the two recorded introductions of WNV in our country, with strains segregating in different sub-clades within lineage 1a. PTRoxo (isolated in 1971) was found to be very similar to an Egyptian WNV strain isolated in 1951, while the viruses isolated in 2004 formed a statistically well-supported group with WNV strains isolated over the last decade in countries lining the Mediterranean (Morocco, Italy, and France). Analyses of the putative amino acid sequences showed all the main expected features described for viral mature proteins except for the absence of the N-glycosylation site in the envelope glycoprotein of PTRoxo, which may be reflected as attenuated neurovirulence and neuroinvasive phenotypes.

West Nile virus in the United States (1999-2005)

The accidental introduction of West Nile Virus into New York City from the Old World in 1999 resulted in an epidemic in humans, horses, and birds that swept to the west coast in just 3 years. The virus is transmitted by infective mosquitoes among susceptible native birds, which serve as amplifying hosts. Clinical disease occurs in humans and horses, but not enough virus is produced in their blood to infect other mosquitoes; therefore, humans and horses are considered dead-end hosts. Humans can best protect themselves by remaining indoors during periods of high mosquito activity and/or by using recommended repellents. Effective vaccines are available for horses.

West Nile virus isolates from India: evidence for a distinct genetic lineage

The complete genomic sequence of one human isolate of West Nile virus (WNV) and the partial genomic sequences of 14 other strains from India isolated in the period 1955-1982 from different hosts and geographical areas were determined. Phylogenetic analyses based on complete and partial genomic sequences (921 nt of the C-prM-E region) revealed that WNV could be classified into five distinct groups that differed from each other by 20-25% at the complete genome level and by 20-26% using partial sequences. Of the Indian isolates, 13 formed a distinct genetic lineage, lineage 5, whereas two isolates, one from a human patient (1967) and another from a bat (1968), were related closely to lineage 1 strains. The complete genomic sequence of the Indian isolate, 804994, showed 20-22% genetic divergence from the previously proposed lineage 1 and 2 strains and 24-25% divergence from isolates of the newly proposed lineages 3 (Rabensburg isolate 97-103 of 1997) and 4 (Russian isolate LEIV-Krnd88-190 of 1998). Similarly, the partial genomic sequences of the Indian isolates showed 21-26% divergence from lineage 1 and 2 strains and from the Rabensburg (97-103) and Russian (LEIV-Krnd88-190) isolates. Cross-neutralization using strain-specific polyclonal antibodies against lineage 1 strain Eg-101 and representative Indian strains suggests substantial antigenic variation. This study documents circulation of WNV strains typical to India for 27 years and the introduction of lineage 1 strains during 1967-1968. These results indicate strongly that WNV should be classified into five genetic lineages, with Indian viruses constituting the distinct genetic lineage 5.

Preparation and immunogenic properties of a recombinant West Nile subunit vaccine

While several West Nile vaccines are being developed, none are yet available for humans. In this study aimed at developing a vaccine for humans, West Nile virus (WNV) envelope protein (E) and non-structural protein 1 (NS1) were produced in the Drosophila S2 cell expression system. The C-terminal 20% of the E protein, which contains the membrane anchor portion, was deleted, thus allowing for efficient secretion of the truncated protein (80E) into the cell culture medium. The proteins were purified by immunoaffinity chromatography (IAC) using monoclonal antibodies that were flavivirus envelope protein group specific (for the 80E) or flavivirus NS1 group specific (for NS1). The purified proteins were produced in high yield and used in conjunction with adjuvant formulations to vaccinate mice. The mice were tested for both humoral and cellular immune responses by a plaque reduction neutralization test and ELISA, and by lymphocyte proliferation and cytokine production assays, respectively. The results revealed that the 80E and the NS1 proteins induced both high-titered ELISA and neutralizing antibodies in mice. Splenocytes from immunized mice, cultured in vitro with the vaccine antigens as stimulants, showed excellent proliferation and production of cytokines (IFN-gamma, IL-4, IL-5, and IL-10). The level of antigen-stimulated lymphocyte proliferation and cytokine production was comparable to the level obtained from mitogen (phytohemagglutinin or pokeweed) stimulation, indicating a robust cellular response as well. These findings are encouraging and warrant further in vivo studies to determine the protective efficacy of the WNV vaccine candidate.

West Nile virus: recent trends in diagnosis and vaccine development

West Nile virus (WNV) is a mosquito-borne flavivirus, native to Africa, Europe, and Western Asia. In many respects, WNV is an outstanding example of a zoonotic pathogen that has leaped geographical barriers and can cause severe disease in human and horse. Before the emergence of WNV in the USA, only few methods of diagnosis were available. Recently, many changes in the fields of WN diagnosis and prevention have happened. This paper will review all these new tools. After a description of the main concerns in WNV and West Nile (WN) disease in humans and animals, this review will present the main available tests for serology and virology detection, from gold standard tests to more recently developed methods. Finally, licensed vaccines and candidate vaccines developed in humans, horses and birds will also been described.

Seroprevalence of West Nile virus in Saskatchewan's Five Hills Health Region, 2003

BACKGROUND

The Five Hills Health Region of Saskatchewan reported the highest West Nile virus (WNV) case rates in the 2003 outbreak. A serologic and telephone survey was undertaken to assess the seroprevalence of the virus and the knowledge, attitudes and behaviours of the residents.

METHODS

Respondents had to be at least 18 years of age, and residents of the Five Hills Health Region between July 1st and September 15th, 2003. Blood samples of respondents were tested at the National Microbiology Laboratory for flavivirus immunoglobulin using a WNV IgG ELISA and plaque reduction neutralization test. Descriptive analyses performed related to respondents' demographics, knowledge, attitudes, behaviours, and seropositivity. WNV infection risk was assessed using odds ratio.

RESULTS

There were 619 questionnaire respondents, of whom 501 donated a blood sample. The seroprevalence of WNV in the Five Hills Health Region was 9.98% (95% CI 7.37-12.59%). Seropositivity of rural areas was 16.8% and urban was 3.2%. Most (97%) of participants thought WNV was an important health issue. Forty-eight percent of the participants used insect repellents containing DEET most of the time. There was good knowledge regarding WNV transmission and prevention of the spread of WNV. Rural compared to urban residents were six times more likely to be positive for WNV (OR=6.13, 95% CI 2.82-13.34).

INTERPRETATION

This is the highest seroprevalence rate of West Nile virus recorded in North America thus far. Many factors could have influenced this outbreak, such as eco-region, early prolonged hot weather, level of mosquito control programs, urban and rural community differences, and personal protective behaviours.

Control of arbovirus infections by a coordinated response: West Nile Virus in England and Wales

Although there is no recognized transmission of human arboviral infections in the UK, concerns about the possible spread of West Nile virus (WNV) have precipitated coordinated activities around both surveillance and response. The Department of Health has chaired a UK WNV task force since the end of 2000. This is a multidisciplinary group of senior representatives from Agencies and Government Departments involved in human and animal health, entomology and academic departments. Activities include surveillance for WNV infections in humans, and in dead birds, mosquitoes and horses. All have been negative for WNV. A WNV contingency plan was produced in 2004, and this could be used as a generic plan for an effective and coordinated response in the event of the emergence of a new vector-borne zoonotic infection.

Transfusion-associated transmission of West Nile virus, United States 2003 through 2005

BACKGROUND

National blood donation screening for West Nile virus (WNV) started in June 2003, after the documentation of WNV transfusion-associated transmission (TAT) in 2002.

STUDY DESIGN AND METHODS

Blood donations were screened with investigational nucleic acid amplification assays in minipool formats. Blood collection agencies (BCAs) reported screening results to state and local public health authorities. Donor test results and demographic information were forwarded to CDC via ArboNET, the national electronic arbovirus surveillance system. State health departments and BCAs also reported suspect WNV TATs to CDC, which investigated these reports to confirm WNV infection in blood transfusion recipients in the absence of likely mosquito exposure.

RESULTS

During 2003 to 2005, a total of 1,425 presumptive viremic donors were reported to CDC from 41 states. Of 36 investigations of suspected WNV TAT in 2003, 6 cases were documented. Estimated viremia levels were available for donations implicated in four TAT cases; the median estimated viremia was 0.1 plaque-forming units (PFUs) per mL (range, 0.06-0.50 PFU/mL; 1 PFU equals approximately 400 copies/mL).

CONCLUSIONS

National blood screening for WNV identified and removed more than 1,400 potentially infectious blood donations in 2003 through 2005. Despite the success of screening in 2003, some residual WNV TAT risk remained due to donations containing very low levels of virus. Screening algorithms employing selected individual-donation testing were designed to address this residual risk and were fully implemented in 2004 and 2005. Continued vigilance for TAT will evaluate the effectiveness of these strategies.

Monoclonal antibody-based competitive enzyme-linked immunosorbent assay for detecting and quantifying West Nile virus-neutralizing antibodies in horse sera

A rapid immunoassay for detecting and quantifying West Nile virus (WNV)-neutralizing antibodies in sera was developed as an alternative to the plaque reduction neutralization test (PRNT), the gold standard test for WNV. The assay is a competitive, enzyme-linked immunosorbent assay using neutralizing monoclonal antibody 5E8 (NT-ELISA). A cutoff percent inhibition (PI) value of 35% (mean PI plus 3 standard deviations), with a specificity of 99%, was established based on analysis of 246 serum samples from horses free of WNV. The NT-ELISA detected neutralizing antibodies in all sera collected 7 or 14 days postinoculation from mice (n = 11) infected with lineage I (strain NY385-99) or II (strain B956) WNV. When sera from WNV-vaccinated horses (n = 212) were tested by NT-ELISA and PRNT, the NT-ELISA gave a positive result for 96.1% (173/180) of the PRNT-positive sera and 3.1% (1/32) of the PRNT-negative sera. Discrepancies between the two tests were observed mainly with sera with low PRNT(90) titers (expressed as the reciprocal of the highest dilution yielding > or = 90% reduction in the number of plaques) for WNV or low PIs by NT-ELISA. The overall agreement (k value) between the two tests was 0.86. A good correlation (r(2) = 0.77) was also observed between the tests for endpoint titration of sera (n = 116). In conclusion, the newly developed NT-ELISA may be a good alternative serologic assay for detecting WNV that can be used for large-scale testing of WNV-neutralizing antibodies in multiple species.

Emerging viral infections in transplantation

Viral infections are an important complication of transplantation. The introduction of more potent immunosuppressive agents over the past decade correlates with an increase in the rate of hospitalizations of transplant patients with infections. Specifically, viral infections have emerged as a major source of morbidity and mortality in transplantation. There are several potential intervention strategies in the face of emerging infections and it is likely that the approach will differ depending on the virus in question. These include viral surveillance and pre-emptive therapy, intervention of the transplant community, and policy change at the level of government, blood bank and organ procurement organizations. This review focuses on the emergence of the herpesviruses; HHV-6 and HHV-7. In addition, the issue of virus transmission through organ transplant is addressed with a discussion of West Nile virus and the rabies virus.

Evaluation of temephos and chlorpyrifos-methyl against Culex pipiens (Diptera: Culicidae) larvae in septic tanks in Antalya, Turkey

The larvicidal activity of chlorpyrifos-methyl and temephos was evaluated against Culex pipiens L. (Diptera: Culicidae) in septic tanks in Antalya, Turkey. Chlorpyrifos-methyl (Pyrifos MT 25 emulsifiable concentrate [EC] ) was evaluated at application rates of 0.04, 0.08, and 0.12 mg active ingredient (AI)/liter, and temephos (Temeguard 50 EC) was evaluated at 0.02, 0.04, and 0.06 mg (AI)/liter during a 21-d study. Generally, overall larval reduction in septic tanks from single- and multifamily dwellings treated with either larvicide was significantly greater than pretreatment levels and control tanks for the duration of the study. At 14 d posttreatment, duration of control was greatest in multifamily tanks treated with chlorpyrifos-methyl at the highest application rate with similar levels of control through 21 d for single-family dwellings (range 97-100%). Septic tanks from both types of family dwellings treated at the highest application rate of temephos resulted in >90% reduction through day 21 (range 91-100%). Laboratory bioassays of septic tank water treated at field application rates, without daily dilution, revealed that complete larval mortality was achieved for 21 d at each application rate and formulation. It is thought that daily addition of water and organic matter to the septic tanks in the single and multifamily dwellings influenced the duration of effectiveness of the larvicides.

Relating West Nile virus case fatality rates to demographic and surveillance variables

OBJECTIVE

The purpose of this ecological study was to relate West Nile virus (WNV) human case fatality rates to county-level demographic and surveillance variables, thereby characterizing the populations to which WNV poses the greatest threat.

METHODS

The authors acquired data on human, avian, and mosquito WNV infections for the 13 states in which there were 100 or more human cases during 2003. The data on avian and mosquito infections were converted into surveillance variables using empirical Bayes methodology. A preliminary logistic regression model was formulated to relate these surveillance variables and demographic variables to case fatality rates. The statistical technique of backward elimination was applied to obtain a final model in terms of the variables most useful for predicting case outcomes.

RESULTS

The probability of a fatal outcome depends on the poverty rate for the county in which the infected person lives (p = 0.0283), the average temperature (p < 0.0001), and surveillance variables reflecting the fractions of Culex pipiens and Culex restuans mosquitoes among infected mosquitoes (p = 0.0079; p = 0.0076).

CONCLUSIONS

Effective WNV educational programs and control measures are vital, especially in poverty-stricken areas. A uniform protocol for disseminating county-level data could facilitate timely responses to WNV outbreaks and to emerging infectious diseases more generally.

Syndromic surveillance in the Netherlands for the early detection of West Nile virus epidemics

West Nile virus (WNV) is an arthropod-borne flavivirus that is endemic in Africa, Europe, and Eastern Asia. The recent introduction and rapid dissemination of the virus in the United States as well as an increase in WNV outbreaks in Europe, has raised concerns for its spread in Europe. A surveillance system was developed to allow timely detection of an introduction of WNV infections in The Netherlands. This program focuses on cases presenting with neurological disease and includes the monitoring of hospital discharge diagnoses, trends in cerebrospinal fluid (CSF) diagnostic requests, laboratory testing of CSF, and monitoring of neurological disease in horses. Retrospective data from the hospital discharge records showed yearly peaks of unexplained meningitis and (meningo)encephalitis in the summer. A total of 781 CSF samples from humans and 71 serum and/or CSF samples from horses presenting with neurological disease of suspected viral etiology tested negative for the presence of specific antibodies to WNV. With a coverage rate of 59% in 2003, the probability that a cluster of five WNV cases presenting with neurological symptoms would have been detected was 99%. We conclude that, from 1999 to 2004, no evidence of WNV infection could be found in either humans or horses in The Netherlands.

Follow-up of 2003 human West Nile virus infections, Denver, Colorado

Tri-County Health Department and Boulder County Public Health conducted a follow-up study of all nonfatal West Nile virus (WNV) cases reported during 2003 in 4 metropolitan Denver, Colorado, counties. Self-reported patient information was obtained ≈6 months after onset. A total of 656 (81.2%) eligible WNV patients are included in this study.

Development of effective therapies against West Nile virus infection

Since its entry into North America in 1999, West Nile virus has spread throughout the USA and Canada, and now annually causes a clinical spectrum of human disease ranging from a self-limiting acute febrile illness to potentially lethal encephalitis. Although no therapy is currently approved for use in humans, several strategies are being pursued to develop effective prophylaxis and treatments. This review describes the epidemiology, clinical presentation and pathogenesis of West Nile virus infection, and highlights recent progress towards an effective therapy.

West Nile virus infections projected from blood donor screening data, United States, 2003

Routine donor nucleic acid amplification testing is a valuable surveillance screening tool.

National blood donor screening for West Nile virus (WNV) RNA using minipool nucleic acid amplification testing (MP-NAT) was implemented in the United States in July 2003. We compiled national NAT yield data and performed WNV immunoglobulin M (IgM) testing in 1 WNV-epidemic region (North Dakota). State-specific MP-NAT yield, antibody seroprevalence, and the average time RNA is detectable by MP-NAT were used to estimate incident infections in 2003. WNV donor screening yielded 944 confirmed viremic donors. MP-NAT yield peaked in August with >0.5% of donations positive for WNV RNA in 4 states. Peak IgM seroprevalence for North Dakota was 5.2% in late September. The average time viremia is detectable by MP-NAT was 6.9 days (95% confidence interval [CI] 3.0–10.7). An estimated 735,000 (95% CI 322,000–1,147,000) infections occurred in 2003, with 256 (95% CI 112–401) infections per neuroinvasive case. In addition to preventing transfusion-transmitted WNV infection, donor screening can serve as a tool to monitor seasonal incidence in the general population.

West Nile encephalitis mimicking herpes encephalitis

A male with a febrile illness, altered consciousness, and seizures was diagnosed with meningoencephalitis. The suspected etiology was herpes simplex virus on the basis of a focal seizure at presentation, and he was treated with acyclovir until this pathogen was excluded. The patient made a complete recovery. Because of a West Nile fever epidemic in Israel at the time, serology tests for West Nile virus were performed; results were positive. This case highlights the diagnostic problems in West Nile fever. The literature is discussed in brief.

Gamma interferon plays a crucial early antiviral role in protection against West Nile virus infection

West Nile virus (WNV) causes a severe central nervous system (CNS) infection in humans, primarily in the elderly and immunocompromised. Prior studies have established an essential protective role of several innate immune response elements, including alpha/beta interferon (IFN-alpha/beta), immunoglobulin M, gammadelta T cells, and complement against WNV infection. In this study, we demonstrate that a lack of IFN-gamma production or signaling results in increased vulnerability to lethal WNV infection by a subcutaneous route in mice, with a rise in mortality from 30% (wild-type mice) to 90% (IFN-gamma(-/-) or IFN-gammaR(-/-) mice) and a decrease in the average survival time. This survival pattern in IFN-gamma(-/-) and IFN-gammaR(-/-) mice correlated with higher viremia and greater viral replication in lymphoid tissues. The increase in peripheral infection led to early CNS seeding since infectious WNV was detected several days earlier in the brains and spinal cords of IFN-gamma(-/-) or IFN-gammaR(-/-) mice. Bone marrow reconstitution experiments showed that gammadelta T cells require IFN-gamma to limit dissemination by WNV. Moreover, treatment of primary dendritic cells with IFN-gamma reduced WNV production by 130-fold. Collectively, our experiments suggest that the dominant protective role of IFN-gamma against WNV is antiviral in nature, occurs in peripheral lymphoid tissues, and prevents viral dissemination to the CNS.

Protective behavior and West Nile virus risk

We conducted a cross-sectional, household survey in Oakville, Ontario, where an outbreak of West Nile virus (WNV) in 2002 led to an unprecedented number of cases of meningitis and encephalitis. Practicing >2 personal protective behavior traits reduced the risk for WNV infection by half.

Chemokine receptor CCR5 promotes leukocyte trafficking to the brain and survival in West Nile virus infection

The molecular immunopathogenesis of West Nile virus (WNV) infection is poorly understood. Here, we characterize a mouse model for WNV using a subcutaneous route of infection and delineate leukocyte subsets and immunoregulatory factors present in the brains of infected mice. Central nervous system (CNS) expression of the chemokine receptor CCR5 and its ligand CCL5 was prominently up-regulated by WNV, and this was associated with CNS infiltration of CD4+ and CD8+ T cells, NK1.1+ cells and macrophages expressing the receptor. The significance of CCR5 in pathogenesis was established by mortality studies in which infection of CCR5-/- mice was rapidly and uniformly fatal. In the brain, WNV-infected CCR5-/- mice had increased viral burden but markedly reduced NK1.1+ cells, macrophages, and CD4+ and CD8+ T cells compared with WNV-infected CCR5+/+ mice. Adoptive transfer of splenocytes from WNV-infected CCR5+/+ mice into infected CCR5-/- mice increased leukocyte accumulation in the CNS compared with transfer of splenocytes from infected CCR5-/- mice into infected CCR5-/- mice, and increased survival to 60%, the same as in infected CCR5+/+ control mice. We conclude that CCR5 is a critical antiviral and survival determinant in WNV infection of mice that acts by regulating trafficking of leukocytes to the infected brain.

West Nile Virus among Hospitalized, Febrile Patients: A Case for Expanding Diagnostic Testing

In Georgia, most individuals reported with West Nile virus (WNV) disease have been diagnosed with West Nile neuroinvasive disease (WNND). Relatively few cases of West Nile Fever (WNF) are reported, and the burden of illness due to WNV is likely underestimated. From July through October 2003, WNV serologic testing was performed on enrolled patients>or=18 years of age with fever admitted to a large, urban hospital in Atlanta, Georgia through the emergency department (ED). Patients' history, clinical, and laboratory data were recorded. Residual blood drawn in the ED was tested to determine the presence of WNV IgG and IgM antibodies. Of 254 patients tested for WNV, four (1.6%) patients were positive for WNV IgM and IgG antibodies, and had a clinical illness compatible with WNV. None of the four positive patients were clinically suspected of having WNV infection; discharge diagnoses included pneumonia, migraine, stroke, and gout. These four patients accounted for 80% of all WNV diagnosed in this hospital, 44% of all cases in Fulton County, and 7% of all cases reported in Georgia in 2003. The occurrence of WNV disease may be substantially greater than currently reflected in disease statistics in Georgia and many other states. When indicators of WNV activity are present and patients are likely to have had intensive mosquito exposure, WNV should be considered in the differential diagnosis of seriously ill, febrile patients.

West Nile Virus Infections Projected from Blood Donor Screening Data, United States, 2003

National blood donor screening for West Nile virus (WNV) RNA using minipool nucleic acid amplification testing (MP-NAT) was implemented in the United States in July 2003. We compiled national NAT yield data and performed WNV immunoglobulin M (IgM) testing in 1 WNV-epidemic region (North Dakota). State-specific MP-NAT yield, antibody seroprevalence, and the average time RNA is detectable by MP-NAT were used to estimate incident infections in 2003. WNV donor screening yielded 944 confirmed viremic donors. MP-NAT yield peaked in August with >0.5% of donations positive for WNV RNA in 4 states. Peak IgM seroprevalence for North Dakota was 5.2% in late September. The average time viremia is detectable by MP-NAT was 6.9 days (95% confidence interval [CI] 3.0-10.7). An estimated 735,000 (95% CI 322,000-1,147,000) infections occurred in 2003, with 256 (95% CI 112-401) infections per neuroinvasive case. In addition to preventing transfusion-transmitted WNV infection, donor screening can serve as a tool to monitor seasonal incidence in the general population.

West Nile virus epidemic, northeast Ohio, 2002

Serum samples and sociodemographic data were obtained from 1,209 Ohio residents. West Nile virus immunoglobulin M (IgM) and IgG antibodies were detected by enzyme-linked immunosorbent assay and confirmed. Children were 4.5 times more likely to become infected yet 110× less likely to have neuroinvasive disease develop.