The first human case of neuroinvasive West Nile virus infection identified in Cyprus

West Nile virus: another emerging arboviral risk for travelers?

Purpose of Review

West Nile virus (WNV) is an arbovirus transmitted by mosquitos of the genus Culex. Manifestations of WNV infection range from asymptomatic to devastating neuroinvasive disease leading to flaccid paralysis and death. This review examines WNV epidemiology and ecology, with an emphasis on travel-associated infection.

Recent Findings

WNV is widespread, including North America and Europe, where its range has expanded in the past decade. Rising temperatures in temperate regions are predicted to lead to an increased abundance of Culex mosquitoes and an increase in their ability to transmit WNV. Although the epidemiologic patterns of WNV appear variable, its geographic distribution most certainly will continue to increase. Travelers are at risk for WNV infection and its complications. Literature review identified 39 cases of documented travel-related WNV disease, the majority of which resulted in adverse outcomes, such as neuroinvasive disease, prolonged recovery period, or death.

Summary

The prediction of WNV risk is challenging due to the complex interactions of vector, pathogen, host, and environment. Travelers planning to visit endemic areas should be advised regarding WNV risk and mosquito bite prevention. Evaluation of ill travelers with compatible symptoms should consider the diagnosis of WNV for those visiting in endemic areas as well as for those returning from destinations with known WNV circulation.

First detection of WNV RNA presence in field-collected mosquitoes in Cyprus

West Nile virus (WNV) infections have increased over recent years to the extent that WNV has become one of the most widespread arboviruses in the world, with potential consequences for both human and animal health. While much is known about WNV and the vectors that transmit it from their primary hosts across continental Europe, little is known about the epidemiology of the disease on the island of Cyprus. In this study, the aim was to investigate the prevalence of WNV infection in potential mosquito vectors for the first time in the Republic of Cyprus, using WNV surveillance of mosquitoes. Mosquitoes were collected in 2019, during which an outbreak in humans had occurred, and sampled mosquitoes were then examined for WNV infection by testing them for the presence of WNV RNA. Of 126 mosquito pools tested, one pool, containing Culex pipiens mosquitoes sampled from the Nicosia district, was found to be positive for the presence of WNV RNA. The positive pool found in this study represents the first demonstration of WNV in mosquitoes in Cyprus and confirms that human cases in Cyprus are likely the result of transmission via local Culex mosquitoes.

An Atypical Presentation of West Nile Virus With Successful Treatment After Plasma Exchange and Intravenous Immunoglobulin

West Nile (WN) disease is a relatively rare arboviral virus. Neuroinvasive cases of WN account for less than 1% of the total cases. The case described had difficult symptomatology and radical presentation, which included ascending paralysis. To date, there have been very few reports of West Nile cases that present with ascending paralysis. We describe the case of a 63-year-old white male who presented with a fever and proximal muscle weakness in the thighs and legs that rapidly worsened and ascended, eventually resulting in diaphragmatic paralysis. He was intubated after respiratory failure and given intravenous immunoglobulin and plasma exchange. The patient remained ventilated with persistent weakness. However, this improved after intravenous immunoglobulin and plasma exchange therapy. This case serves as a reminder to keep the diagnosis of WN on the differential, a primer on advanced treatments in the setting of aggressive atypical WN, and a lesson on similarly presenting diseases and distinguishing characteristics that may help rule out these diseases from WN.

Impact of meteorological parameters on mosquito population abundance and distribution in a former malaria endemic area, central Iran

Meteorological parameters, have been identified as an important factor involved in the transmission of vector-borne diseases. Mosquitoes are extremely sensitive to weather conditions. The aim of this study was investigate the correlation between meteorological parameters and the abundance of mosquitoes in Kashan County. Mosquitoes were collected using four different traps, including hand catch, animal baited bed net trap (usually a cow), human baited bed net trap and BG-Sentinel trap with CO2 from May to December 2019. A total number of mosquitoes collected were 1756 out of which 1621 (92.31%) were Culex, 22 (1.25%) Culiseta and 113 (6.44%) Anopheles in nine species. Most mosquitoes were collected by BG-Sentinel trap with CO2 (63.78%). Monthly distribution of the mosquitoes indicated different monthly peaks. Their high density were recorded in September and were low in December. The spearman's correlation of the mosquito abundance and the meteorological parameters shows that correlation of the number of total collected mosquitoes with relative humidity and precipitation (Rainfall) was weak negative, and there was week correlation with wind speed, and positive strong correlation with temperature. Data collected with various trap types and mosquito correlation with meteorological parameters in this study can be used for mosquito surveillance and control programs. However, meteorological parameters affect the abundance of mosquitoes, but their impact is complex and most of these variables are species specific.

Evidence of West Nile virus seropositivity in wild birds on the island of Cyprus

West Nile Virus (WNV)¹ is an emerging pathogen in Cyprus, with the first human case of infection reported in 2016, and another documented in 2018. A cluster of cases in humans was then reported in 2019. However, little is known regarding which avian species might bring WNV to Cyprus. Here, we investigated seroprevalence of WNV antibodies in migratory and resident birds, captured across Cyprus to assess to what extent human populations might be exposed to WNV. We used Enzyme-Linked Immunosorbent Assay (ELISA)² to test for the presence of WNV antibodies in 836 avian blood samples of 44 species captured between 2015 and 2020. A seropositivity rate of 1.3 % was found. The majority of seropositive wild birds belonged to the migratory species Sylvia atricapilla, a common and widespread migrant, implying a high risk of WNV being introduced throughout Cyprus.

Epidemiologic and phylogenetic analysis of the 2018 West Nile virus (WNV) outbreak in Israel demonstrates human infection of WNV lineage I

As at 12 November 2018, an outbreak of West Nile virus (WNV) was responsible for 139 WNV infection cases in Israel. Here, we characterise the epidemiology of the outbreak and demonstrate that only WNV lineage I was circulating in mosquitoes and responsible for WNV infection in humans. This suggests that the concurrence of the outbreak in Israel with WNV outbreaks in several European countries is not due to a common, more virulent WNV genotype.

The Effect of Weather Variables on Mosquito Activity: A Snapshot of the Main Point of Entry of Cyprus

Mosquitoes are vectors of pathogens, causing human and animal diseases. Their ability to adapt and expand worldwide increases spread of mosquito-borne diseases. Climate changes contribute in enhancing these “epidemic conditions”. Understanding the effect of weather variables on mosquito seasonality and host searching activity contributes towards risk control of the mosquito-borne disease outbreaks. To enable early detection of Aedes invasive species we developed a surveillance network for both invasive and native mosquitoes at the main point of entry for the first time in Cyprus. Mosquito sampling was carried out for one year (May 2017–June 2018), at bimonthly intervals around Limassol port. Morphological and molecular identification confirmed the presence of 5 species in the study region: Culex. pipiens, Aedes detritus, Ae. caspius, Culiseta longiareolata and Cs. annulata. No invasive Aedes mosquito species were detected. The Pearson’s correlation and multiple linear regression were used to compare number of sampled mosquitoes and weather variables for three most numerous species (Cx. pipiens, Ae. detritus and Ae. caspius). The population densities of the most numerous species were highest from February to April. Number of Cx. pipiens (−0.48), Ae. detritus (−0.40) and Ae. caspius (−0.38) specimens sampled was negatively correlated with average daily temperature. Monthly relative humidity showed positive correlation with the numbers of the species sampled, Cx. pipiens (0.66) Ae. detritus (0.68), and Ae. caspius (0.71). Mosquito abundance of Cx. pipiens (0.97) and Ae. detritus (0.98) was strongly correlated to seasonal precipitation as well. Our work is a stepping stone to further stimulate implementation of International Health Regulations and implementation of early warning surveillance system for detection of invasive Aedes mosquitoes, native mosquitoes and arboviruses they may transmit. A network for the surveillance of both invasive and native mosquito species at the main point of entry for the first time in Cyprus was developed. Number of mosquitoes sampled was correlated with weather factors to identify parameters that might predict mosquito activity and species distribution to the prevention of international spread of vector mosquitoes and vector-borne diseases.

Serological screening of West Nile virus among blood donors in northern Cyprus

BACKGROUND

West Nile virus (WNV) is a neurotropic arbovirus that can also be transmitted through blood transfusion. Even though its geographic distribution has been expanding, there has not yet been any epidemiological data on WNV in northern Cyprus. The aim of our study is to fill this gap by using donated blood samples.

METHODS

Samples collected from the main government hospital blood bank in Nicosia were analyzed by anti-WNV enzyme-linked immunosorbent assay (ELISA) (immunoglobulin M [IgM] and immunoglobulin G [IgG]). Seropositive samples were subjected to plaque reduction neutralization test (PRNT) for confirmation and analyzed by ELISA IgG avidity test and reverse transcription real-time polymerase chain reaction (rRT-PCR).

RESULTS

Of the 760 sera samples, 2 (0.3%) were IgM+ and 31 (4.1%) were IgG+. Neutralization activity was detected in none (0.0%) of the IgM+ and 26 (83.9%) of IgG+ donor specimens. ELISA IgG avidity test reported high avidity in 21 (67.7%) and low avidity in one (3.2%) IgG+ sample. PRNT-confirmed anti-WNV IgG+ samples exhibited only borderline (19.2%) or high avidity (80.8%) values. rRT-PCR results were negative for both IgM+ and IgG+ samples.

CONCLUSION

Anti-WNV antibodies were detected in northern Cyprus among blood donors. The establishment of preventive measures and evaluation of the geographic extent of the WNV in northern Cyprus are highly recommended.

Multi-Approach Investigation Regarding the West Nile Virus Situation in Hungary, 2018

The West Nile virus is endemic in multiple European countries and responsible for several epidemics throughout the European region. Its evolution into local or even widespread epidemics is driven by multiple factors from genetic diversification of the virus to environmental conditions. The year of 2018 was characterized by an extraordinary increase in human and animal cases in the Central-Eastern European region, including Hungary. In a collaborative effort, we summarized and analyzed the genetic and serologic data of WNV infections from multiple Hungarian public health institutions, universities, and private organizations. We compared human and veterinary serologic data, along with NS5 and NS3 gene sequence data through 2018. Wild birds were excellent indicator species for WNV circulation in each year. Our efforts resulted in documenting the presence of multiple phylogenetic subclades with Balkans and Western-European progenitor sequences of WNV circulating among human and animal populations in Hungary prior to and during the 2018 epidemic. Supported by our sequence and phylogenetic data, the epidemic of 2018 was not caused by recently introduced WNV strains. Unfortunately, Hungary has no country-wide integrated surveillance system which would enable the analysis of related conditions and provide a comprehensive epidemiological picture. The One Health approach, involving multiple institutions and experts, should be implemented in order to fully understand ecological background factors driving the evolution of future epidemics.

West Nile virus - a new infection in the Slovak Republic?

OBJECTIVE

The aim of the study was to evaluate the seroprevalence of West Nile virus (WNV) among the variable population of Eastern Slovakia.

METHODS

A serologic survey was conducted using 464 serum samples. The basic demographic, epidemiologic and clinical information was obtained for each serum sample at the time of specimen collection. The presence of antibodies against WNV was investigated using a commercial enzyme-linked immunosorbent assay (ELISA). All the ELISA positive samples were further analysed by a neutralization test with WNV and Usutu virus.

RESULTS

Three serum samples (0.65%) from the participants (N = 464) were considered positive for antibodies to WNV. A 29-year-old female was repeatedly exposed to mosquito bites working as a shepherdess and participating in many outdoor activities. Two other females (61 and 76 years old) were treated at the Department of Neurology due to monoparesis of the upper extremity, vertigo; both had a significant epidemiological history with frequent tick and mosquito bites and stay in an endemic region.

CONCLUSIONS

Although there was no evidence of WNV infection in the Slovak Republic, the epidemiological situation in the neighbouring countries warrants vigilance and appropriate measures, including the introduction of specific diagnostic tools into clinical practice. The constant monitoring of birds and mosquitoes also seems necessary.

Emerging Trends in the Epidemiology of West Nile and Usutu Virus Infections in Southern Europe

The epidemiology of West Nile (WNV) and Usutu virus (USUV) has changed dramatically over the past two decades. Since 1999, there have been regular reports of WNV outbreaks and the virus has expanded its area of circulation in many Southern European countries. After emerging in Italy in 1996, USUV has spread to other countries causing mortality in several bird species. In 2009, USUV seroconversion in horses was reported in Italy. Co-circulation of both viruses was detected in humans, horses and birds. The main vector of WNV and USUV in Europe is Culex pipiens, however, both viruses were found in native Culex mosquito species (Cx. modestus, Cx. perexiguus). Experimental competence to transmit the WNV was also proven for native and invasive mosquitoes of Aedes and Culex genera (Ae. albopictus, Ae. detritus, Cx. torrentium). Recently, Ae. albopictus and Ae. japonicus naturally-infected with USUV were reported. While neuroinvasive human WNV infections are well-documented, USUV infections are sporadically detected. However, there is increasing evidence of a role of USUV in human disease. Seroepidemiological studies showed that USUV circulation is more common than WNV in some endemic regions. Recent data showed that WNV strains detected in humans, horses, birds, and mosquitoes mainly belong to lineage 2. In addition to European USUV lineages, some reports indicate the presence of African USUV lineages as well. The trends in WNV/USUV range and vector expansion are likely to continue in future years. This mini-review provides an update on the epidemiology of WNV and USUV infections in Southern Europe within a multidisciplinary "One Health" context.

Complete Genome Sequence of West Nile Virus (WNV) from the First Human Case of Neuroinvasive WNV Infection in Cyprus

We report here the complete genome sequence of a West Nile virus (WNV) strain from the first laboratory-confirmed human case of neuroinvasive WNV infection in Cyprus. Phylogenetic analysis showed that this WNV strain grouped clearly into genetic lineage 1, clade 1a, cluster 2.