Epidemiologic and clinical parameters of West Nile virus infections in humans: a scoping review

Seroprevalence of West Nile Virus among Equids in Bulgaria in 2022 and Assessment of Some Risk Factors

The aim of this study was to analyze the seroprevalence of West Nile virus (WNV) among equids in Bulgaria, confirm the results of a competitive ELISA versus the virus neutralization test (VNT) and investigate some predisposing factors for WNV seropositivity. A total of 378 serum samples from 15 provinces in northern and southern Bulgaria were tested. The samples originated from 314 horses and 64 donkeys, 135 males and 243 females, aged from 1 to 30 years. IgG and IgM antibodies against WNV protein E were detected by ELISA. ELISA-positive samples were additionally tested via VNT for WNV and Usutu virus. Thirty-five samples were WNV-positive by ELISA (9.26% [CI = 6.45-12.88]), of which 15 were confirmed by VNT; hence, the seroprevalence was 3.97% (CI = 2.22-6.55). No virus-neutralizing antibodies to Usutu virus were detected among the 35 WNV-ELISA-positive equids in Bulgaria. When compared with VNT, ELISA showed 100.0% sensitivity and 94.5% specificity. A statistical analysis showed that the risk factors associated with WNV seropositivity were the region (p < 0.0001), altitude of the locality (p < 0.0001), type of housing (p < 0.0001) and breed (p = 0.0365). The results of the study demonstrate, albeit indirectly, that WNV circulates among equids in northern and southern Bulgaria, indicating that they could be suitable sentinel animals for predicting human cases and determining the risk in these areas or regions of the country.

Inflammatory Response Associated with West Nile Neuroinvasive Disease: A Systematic Review

BACKGROUND

West Nile virus (WNV) infection is a seasonal arbovirosis with the potential to cause severe neurological disease. Outcomes of the infection from WNV depend on viral factors (e.g., lineage) and host-intrinsic factors (e.g., age, sex, immunocompromising conditions). Immunity is essential to control the infection but may also prove detrimental to the host. Indeed, the persistence of high levels of pro-inflammatory cytokines and chemokines is associated with the development of blood-brain barrier (BBB) damage. Due to the importance of the inflammatory processes in the development of West Nile neuroinvasive disease (WNND), we reviewed the available literature on the subject.

METHODS

According to the 2020 updated PRISMA guidelines, all peer-reviewed articles regarding the inflammatory response associated with WNND were included.

RESULTS

One hundred and thirty-six articles were included in the data analysis and sorted into three groups (in vitro on-cell cultures, in vivo in animals, and in humans). The main cytokines found to be increased during WNND were IL-6 and TNF-α. We highlighted the generally small quantity and heterogeneity of information about the inflammatory patterns associated with WNND.

CONCLUSIONS

Further studies are needed to understand the pathogenesis of WNND and to investigate the extent and the way the host inflammatory response either helps in controlling the infection or in worsening the outcomes. This might prove useful both for the development of target therapies and for the development of molecular markers allowing early identification of patients displaying an inflammatory response that puts them at a higher risk of developing neuroinvasive disease and who might thus benefit from early antiviral therapies.

Abrupt Increase in Detection of Locally Acquired West-Nile-Virus-Lineage-2-Mediated Neuroinvasive Disease in a Previously Non-Endemic Area of Southern Italy (2023)

West Nile virus (WNV) is a public health concern in Europe. Rising temperatures and the migration of potential vectors promote the spread of viruses to previously unaffected areas. In 2023, the Apulia region of Southern Italy experienced an unexpected increase in West Nile neuroinvasive disease (WNND); no such cases had been reported in the previous 10 years. Overall, eight autochthonous cases of WNV infection were identified between July and October 2023, six of which were WNND. All cases were male (median age, 73 years). Two of the cases were blood donors. All WNND cases were hospitalized and all recovered within a few weeks. Surveillance data showed that, in the Apulia region, WNV Lineage 2 was detected in humans, mosquitoes, and horses. Based on the number of WNND cases reported, we can assume that a high number of infections occurred during the summer period. Changes in the climate in the region over recent years could be considered among the main drivers of the rapid increase in WNV infections. Therefore, integrated surveillance should be strengthened to avoid the potential massive spread of WNV in Southern Italy. Moreover, the implementation of whole-genome sequencing of WNV strains, as well as seroepidemiological studies in the area, will facilitate a better understanding of circulation dynamics.

First Detection of West Nile Virus Lineage 2 in Mosquitoes in Switzerland, 2022

West Nile virus (WNV) is one of the most widespread flaviviruses in the world, and in recent years, it has been frequently present in many Mediterranean and Eastern European countries. A combination of different conditions, such as a favourable climate and higher seasonal average temperatures, probably allowed its introduction and spread to new territories. In Switzerland, autochthonous cases of WNV have never been reported, and the virus was not detected in mosquito vectors until 2022, despite an entomological surveillance in place in Canton Ticino, southern Switzerland, since 2010. In 2022, 12 sites were monitored from July to October, using BOX gravid mosquito traps coupled with honey-baited FTA cards. For the first time, we could detect the presence of WNV in FTA cards and mosquitoes in 8 out of the 12 sampling sites monitored, indicating an unexpectedly widespread circulation of the virus throughout the territory. Positive findings were recorded from the beginning of August until mid-October 2022, and whole genome sequencing analysis identified a lineage 2 virus closely related to strains circulating in Northern Italy. The entomological surveillance has proved useful in identifying viral circulation in advance of possible cases of WNV infection in humans or horses.

Ecological and clinical evidence of the establishment of West Nile virus in a large urban area in Europe, Berlin, Germany, 2021 to 2022

BackgroundWest Nile virus (WNV), found in Berlin in birds since 2018 and humans since 2019, is a mosquito-borne virus that can manifest in humans as West Nile fever (WNF) or neuroinvasive disease (WNND). However, human WNV infections and associated disease are likely underdiagnosed.AimWe aimed to identify and genetically characterise WNV infections in humans and mosquitoes in Berlin.MethodsWe investigated acute WNV infection cases reported to the State Office for Health and Social Affairs Berlin in 2021 and analysed cerebrospinal fluid (CSF) samples from patients with encephalitis of unknown aetiology (n = 489) for the presence of WNV. Mosquitoes were trapped at identified potential exposure sites of cases and examined for WNV infection.ResultsWest Nile virus was isolated and sequenced from a blood donor with WNF, a symptomatic patient with WNND and a WNND case retrospectively identified from testing CSF. All cases occurred in 2021 and had no history of travel 14 days prior to symptom onset (incubation period of the disease). We detected WNV in Culex pipiens mosquitoes sampled at the exposure site of one case in 2021, and in 2022. Genome analyses revealed a monophyletic Berlin-specific virus clade in which two enzootic mosquito-associated variants can be delineated based on tree topology and presence of single nucleotide variants. Both variants have highly identical counterparts in human cases indicating local acquisition of infection.ConclusionOur study provides evidence that autochthonous WNV lineage 2 infections occurred in Berlin and the virus has established an endemic maintenance cycle.

Effects of climatic and environmental factors on mosquito population inferred from West Nile virus surveillance in Greece

Mosquito-borne diseases' impact on human health is among the most prominent of all communicable diseases. With limited pool of tools to contrast these diseases, public health focus remains preventing mosquito-human contacts. Applying a hierarchical spatio-temporal Bayesian model on West Nile virus (WNV) surveillance data from Greece, we aimed to investigate the impact of climatic and environmental factors on Culex mosquitoes' population. Our spatio-temporal analysis confirmed climatic factors as major drivers of WNV-transmitting-Culex mosquitoes population dynamics, with temperature and long periods of moderate-to-warm climate having the strongest positive effect on mosquito abundance. Conversely, rainfall, high humidity, and wind showed a negative impact. The results suggest the presence of statistically significant differences in the effect of regional and seasonal characteristics, highlighting the complex interplay between climatic, geographical and environmental factors in the dynamics of mosquito populations. This study may represent a relevant tool to inform public health policymakers in planning preventive measures.

Demographic characteristics associated with West Nile virus neuroinvasive disease - A retrospective study on the wider European area 2006-2021

BACKGROUND

With a case-fatality-risk ranging from 3.0 to >20.0% and life-long sequelae, West Nile neuroinvasive disease (WNND) is the most dangerous outcome of West Nile virus (WNV) infection in humans. As no specific prophylaxis nor therapy is available for these infections, focus is on preventive strategies. We aimed to find variables associated with WNND diagnosis, hospitalisation or death, to identify high-risk sub-groups of the population, on whom to concentrate these strategies.

METHODS

We used data from The European Surveillance System-TESSy, provided by National Public Health Authorities, and released by the European Centre for Disease Prevention and Control (ECDC). In two Firth-penalised logistic regression models, we considered age, sex, clinical criteria, epidemiological link to other cases (epi-link), calendar year, and season as potential associated variables. In one model we considered also the rural/urban classification of the place of infection (RUC), while in the other the specific reporting country.

FINDINGS

Among confirmed West Nile Virus cases, 2,916 WNND cases were registered, of which 2,081 (71.4%), and 383 (13.1%) resulted in the hospitalisation and death of the patient, respectively. Calendar year, RUC/country, age, sex, clinical criteria, and epi-link were associated with WNND diagnosis. Hospitalisation was associated with calendar year and RUC/country; whereas death was associated with age, sex and country.

INTERPRETATION

Our results support previous findings on WNND associated variables (most notably age and sex); while by observing the whole population of WNND cases in the considered area and period, they also allow for stronger generalizations, conversely to the majority of previous studies, which used sample populations.

Comparison of West Nile Virus Disease in Humans and Horses: Exploiting Similarities for Enhancing Syndromic Surveillance

West Nile virus (WNV) neuroinvasive disease threatens the health and well-being of horses and humans worldwide. Disease in horses and humans is remarkably similar. The occurrence of WNV disease in these mammalian hosts has geographic overlap with shared macroscale and microscale drivers of risk. Importantly, intrahost virus dynamics, the evolution of the antibody response, and clinicopathology are similar. The goal of this review is to provide a comparison of WNV infection in humans and horses and to identify similarities that can be exploited to enhance surveillance methods for the early detection of WNV neuroinvasive disease.

Vaccination of Zoo Birds against West Nile Virus-A Field Study

West Nile virus (WNV) is known to cause disease and death in humans and various animals worldwide. WNV has circulated in Germany since 2018. In 2020, four birds tested positive for the WNV genome at Zoopark Erfurt (Thuringia). Moreover, virus neutralization assays detected neutralizing antibodies (nAb) against WNV in 28 birds. In addition, nAb against WNV and Usutu virus (USUV) were found in 14 birds. To protect valuable animals and to reduce the risk of viral transmission from birds to humans, we performed a field study on WNV vaccination at the zoo. To conduct the study, 61 birds from the zoo were categorized into three groups and subjected to a vaccination regimen, where each bird received either 1.0 mL, 0.5 mL, or 0.3 mL of a commercial inactivated WNV vaccine three times. The vaccinations were administered at three-week intervals, or as per modified vaccination schedules. Furthermore, 52 birds served as non-vaccinated controls. Adverse vaccination reactions were absent. The greatest increase in nAb titres was observed in birds that received 1.0 mL of vaccine. However, pre-existing antibodies to WNV and USUV appeared to have a major effect on antibody development in all groups and in all bird species, whereas sex and age had no effect. After vaccination, no death was detected in vaccinated birds for more than 1 year.

Autochthonous West Nile Virus Infection Outbreak in Humans (Asti, Piedmont, Italy, August–October 2018) and Long-Term Sequelae Follow-Up

West Nile virus (WNV) infection is a reemerging zoonosis recently provoking significant outbreaks throughout Europe. During the summer of 2018, the number of WNV infections rose with a peak of new diagnoses of West Nile neuro-invasive disease (WNND). Most of the Italian cases were clustered in the Po River Valley. We present a case series of nine patients with WNV infection admitted to the Cardinal Massaia Hospital from 30 August 2018 to 1 October 2018. Demographic, immunovirological, clinical and therapeutic data are shown, and a report on clinical sequelae from the subsequent follow-up in patients with WNV and WNND. We showed the clinical, radiological and biochemical characteristics of WNV-infected patients. The risk factors and the clinical presentation of WNV in most patients in our case series were typical of that described in the literature, although, despite the high morbidity and mortality of WNND, we showed survival of 100% and long-term sequelae in only three patients. Environmental conditions may be essential in WNV outbreaks, and WNND can be clinically neurological multiform. Our long-lasting follow-up with clinical or radiological monitoring confirmed the morbidity of long-term neurological sequelae after WNND. Further studies are needed to investigate the epidemiology and physiopathology of bacterial superinfections after WNV infection.

An Examination of the Intersection of Climate Change, the Physician Specialty Workforce, and Graduate Medical Education in the U.S

Issue: As U.S. healthcare systems plan for future physician workforce needs, the systemic impacts of climate change, a worldwide environmental and health crisis, have not been factored in. The current focus on increasing the number of trained physicians and optimizing efficiencies in healthcare delivery may be insufficient. Graduate medical education (GME) priorities and training should be considered in order to prepare a climate-educated physician workforce. Evidence: We used a holistic lens to explore the available literature regarding the intersection of future physician workforce needs, GME program priorities, and resident education within the larger context of climate change. Our interinstitutional, transdisciplinary team brought perspectives from their own fields, including climate science, climate and health research, and medical education to provide recommendations for building a climate-educated physician workforce. Implications: Acknowledging and preparing for the effects of climate change on the physician workforce will require identification of workforce gaps, changes to GME program priorities, and education of trainees on the health and societal impacts of climate change. Alignment of GME training with workforce considerations and climate action and adaptation initiatives will be critical in ensuring the U.S. has a climate-educated physician workforce capable of addressing health and healthcare system challenges. This article offers a number of recommendations for physician workforce priorities, resident education, and system-level changes to better prepare for the health and health system impacts of climate change.

Comorbid conditions as risk factors for West Nile neuroinvasive disease in Ontario, Canada: a population-based cohort study

West Nile neuroinvasive disease (WNND) is a severe neurological illness that can result from West Nile virus (WNV) infection, with long-term disability and death being common outcomes. Although WNV arrived in North America over two decades ago, risk factors for WNND are still being explored. The objective of this study was to identify WNND comorbid risk factors in the Ontario population using a retrospective, population-based cohort design. Incident WNV infections from laboratory records between 1 January 2002 – 31 December 2012 were individually-linked to health administrative databases to ascertain WNND outcomes and comorbid risk factors. WNND incidence was compared among individuals with and without comorbidities using risk ratios (RR) calculated with log binomial regression.

Three hundred and forty-five individuals developed WNND (18.3%) out of 1884 WNV infections. West Nile encephalitis was driving most associations with comorbidities. Immunocompromised (aRR 2.61 [95% CI 1.23–4.53]) and male sex (aRR 1.32 [95% CI 1.00–1.76]) were risk factors for encephalitis, in addition to age, for which each 1-year increase was associated with a 2% (aRR 1.02 [95% CI 1.02–1.03]) relative increase in risk. Our results suggest that individuals living with comorbidities are at higher risk for WNND, in particular encephalitis, following WNV infection.

Seroepidemiological Survey of West Nile Virus Infections in Horses from Berlin/Brandenburg and North Rhine-Westphalia, Germany

Following the introduction of the West Nile virus (WNV) into eastern Germany in 2018, increasing infections have been diagnosed in birds, equines, and humans over time, while the spread of WNV into western Germany remained unclear. We screened 437 equine sera from 2018 to 2020, excluding vaccinated horses, collected from convenience sampled patients in the eastern and western parts of Germany, for WNV-specific antibodies (ELISAs followed by virus/specific neutralization tests) and genomes (RT-qPCRs). Clinical presentations, final diagnoses, and demographic data were also recorded. In the eastern part, a total of eight horses were found WNV seropositive in 2019 (seroprevalence of 8.16%) and 27 in 2020 (13.77%). There were also two clinically unsuspected horses with WNV-specific antibodies in the western part from 2020 (2.63%), albeit travel history-related infections could not be excluded. None of the horse sera contained WNV-specific genomes. Eight horses in eastern Germany carried WNV-IgM antibodies, but only four of these showed typical clinical signs. These results underline the difficulty of detecting a WNV infection in a horse solely based on clinical signs. Thus, WNV circulation is established in the horse population in eastern Germany, but not yet in the western part.

West Nile Virus-Associated Hospitalizations, California, 2004-2017

BACKGROUND

West Nile virus (WNV) is the most commonly reported mosquito-borne disease in the USA. California reports more WNV disease than any other state.

METHODS

We identified WNV-associated hospitalizations from 2004 through 2017 in California and estimated hospitalization incidence using Patient Discharge Data. We described demographic, geographic, and clinical characteristics of WNV hospitalizations; identified risk factors for in-hospital death; and tabulated hospitalization charges.

RESULTS

From 2004 through 2017, 3109 Californians were hospitalized with WNV (median, 214 patients/year; range, 72-449). The majority were male (1983; 63.8%) and aged ≥60 years (1766; 56.8%). The highest median annual hospitalization rate (0.88 hospitalizations/100 000 persons) was in the Central Valley, followed by southern California (0.59 hospitalizations/100 000 persons). Most patients (2469; 79.4%) had ≥1 underlying condition, including hypertension, cardiovascular disease, diabetes, chronic kidney disease, or immunosuppression due to medications or disease. Median hospitalization length of stay was 12 days (interquartile range, 6-23 days). During hospitalization, 1317 (42%) patients had acute respiratory failure and/or sepsis/septic shock, 772 (24.8%) experienced acute kidney failure, and 470 (15.1%) had paralysis; 272 (8.8%) patients died. Nearly 47% (1444) of patients were discharged for additional care. During these 14 years, $838 680 664 (mean $59.9 million/year) was charged for WNV hospitalizations, 73.9% through government payers at a median charge of $142 321/patient.

CONCLUSIONS

WNV-associated hospitalizations were substantial and costly in California. Hospitalization incidence was higher in males, elderly persons, and patients with underlying conditions. WNV persists as a costly and severe public health threat in California.

Pathogenicity and virulence of West Nile virus revisited eight decades after its first isolation

West Nile virus (WNV) is a flavivirus which transmission cycle is maintained between mosquitoes and birds, although it occasionally causes sporadic outbreaks in horses and humans that can result in serious diseases and even death. Since its first isolation in Africa in 1937, WNV had been considered a neglected pathogen until its recent spread throughout Europe and the colonization of America, regions where it continues to cause outbreaks with severe neurological consequences in humans and horses. Although our knowledge about the characteristics and consequences of the virus has increased enormously lately, many questions remain to be resolved. Here, we thoroughly update our knowledge of different aspects of the WNV life cycle: virology and molecular classification, host cell interactions, transmission dynamics, host range, epidemiology and surveillance, immune response, clinical presentations, pathogenesis, diagnosis, prophylaxis (antivirals and vaccines), and prevention, and we highlight those aspects that are still unknown and that undoubtedly require further investigation.

Virus infection of the CNS disrupts the immune-neural-synaptic axis via induction of pleiotropic gene regulation of host responses

Treatment for many viral infections of the central nervous system (CNS) remains only supportive. Here we address a remaining gap in our knowledge regarding how the CNS and immune systems interact during viral infection. By examining the regulation of the immune and nervous system processes in a nonhuman primate model of West Nile virus neurological disease, we show that virus infection disrupts the homeostasis of the immune-neural-synaptic axis via induction of pleiotropic genes with distinct functions in each component of the axis. This pleiotropic gene regulation suggests an unintended off-target negative impact of virus-induced host immune responses on the neurotransmission, which may be a common feature of various viral infections of the CNS.

Clinical Signs, Prevention and Treatment of Viral Infections in Infants

Certain infectious diseases are common in infants than any other age groups and are associated with morbidities in childhood and adulthood, and even mortality in severe cases. Environment, epidemic and maternal immunity are the main causes of these infections. Early diagnosis using molecular methods and treatment is therefore important to prevent future complications. Vaccines are recommended during infancy and childhood to prevent these infections. This review highlights some of the most commonly reported viral infections in children, their clinical signs, prevention and treatment.

In-Depth Analysis of Genetic Variation Associated with Severe West Nile Viral Disease

West Nile virus (WNV) is a mosquito-borne virus which causes symptomatic disease in a minority of infected humans. To identify novel genetic variants associated with severe disease, we utilized data from an existing case-control study of WNV and included population controls for an expanded analysis. We conducted imputation and gene-gene interaction analysis in the largest and most comprehensive genetic study conducted to date for West Nile neuroinvasive disease (WNND). Within the imputed West Nile virus dataset (severe cases n = 381 and asymptomatic/mild controls = 441), we found novel loci within the MCF.2 Cell Line Derived Transforming Sequence Like (MCF2L) gene (rs9549655 and rs2297192) through the individual loci analyses, although none reached statistical significance. Incorporating population controls from the Wisconsin Longitudinal Study on Aging (n = 9012) did not identify additional novel variants, a possible reflection of the cohort's inclusion of individuals who could develop mild or severe WNV disease upon infection. Many of the top gene-gene interaction results were intergenic, with currently undefined biological roles, highlighting the need for further investigation into these regions and other identified gene targets in severe WNND. Further studies including larger sample sizes and more diverse populations reflective of those at risk are needed to fully understand the genetic architecture of severe WNDD and provide guidance on viable targets for therapeutic and vaccine development.

West Nile virus neuroinvasive disease associated with rituximab therapy

West Nile virus neuroinvasive disease (WNVND) manifests with meningitis, encephalitis, and/or acute flaccid paralysis. It represents less than 1% of the clinical syndromes associated with West Nile virus (WNV) infection in immunocompetent patients. Immunosuppressive therapy is associated with increased risk of WNVND and worse prognosis. We present a patient with WNVND during therapy with rituximab, and a review of the literature for previous similar cases with the goal to describe the clinical spectrum of WNVND in patients treated specifically with rituximab. Our review indicates that the most common initial complaints are fever and altered mental status, brain magnetic resonance imaging often shows bilateral thalamic hyperintensities, and cerebrospinal analysis consistently reveals mild lymphocytic pleocytosis with elevated protein, positive WNV polymerase chain reaction, and negative WNV antibodies. Treatment is usually supportive care, with intravenous immunoglobulins (IVIG) plus corticosteroids and WNV-specific IVIG also used. The disease is usually fatal despite intervention. Our patient's presentation was very similar to prior reports, however demonstrated spontaneous improvement with supportive management only. WNVND is a rare and serious infection with poor prognosis when associated with rituximab therapy. Diagnosis is complicated by absent or delayed development of antibodies. The presence of bilateral thalamic involvement is a diagnostic clue for WNVND. There is insufficient evidence to recommend the use of corticosteroids or IVIG.

West Nile Virus Epidemic in Germany Triggered by Epizootic Emergence, 2019

One year after the first autochthonous transmission of West Nile virus (WNV) to birds and horses in Germany, an epizootic emergence of WNV was again observed in 2019. The number of infected birds and horses was considerably higher compared to 2018 (12 birds, two horses), resulting in the observation of the first WNV epidemy in Germany: 76 cases in birds, 36 in horses and five confirmed mosquito-borne, autochthonous human cases. We demonstrated that Germany experienced several WNV introduction events and that strains of a distinct group (Eastern German WNV clade), which was introduced to Germany as a single introduction event, dominated mosquito, birds, horse and human-related virus variants in 2018 and 2019. Virus strains in this clade are characterized by a specific-Lys2114Arg mutation, which might lead to an increase in viral fitness. Extraordinary high temperatures in 2018/2019 allowed a low extrinsic incubation period (EIP), which drove the epizootic emergence and, in the end, most likely triggered the 2019 epidemic. Spatiotemporal EIP values correlated with the geographical WNV incidence. This study highlights the risk of a further spread in Germany in the next years with additional human WNV infections. Thus, surveillance of birds is essential to provide an early epidemic warning and thus, initiate targeted control measures.

Lack of Efficacy of High-Titered Immunoglobulin in Patients with West Nile Virus Central Nervous System Disease

Immunoglobulin administered to adults with neuroinvasive disease appeared to be safe but was not demonstrated to improve clinical outcomes.

West Nile Virus (WNV) can result in clinically severe neurologic disease. There is no treatment for WNV infection, but administration of anti-WNV polyclonal human antibody has demonstrated efficacy in animal models. We compared Omr-IgG-am, an immunoglobulin product with high titers of anti-WNV antibody, with intravenous immunoglobulin (IVIG) and normal saline to assess safety and efficacy in patients with WNV neuroinvasive disease as part of a phase I/II, randomized, double-blind, multicenter study in North America. During 2003–2006, a total of 62 hospitalized patients were randomized to receive Omr-IgG-am, standard IVIG, or normal saline (3:1:1). The primary endpoint was medication safety. Secondary endpoints were morbidity and mortality, measured using 4 standardized assessments of cognitive and functional status. The death rate in the study population was 12.9%. No significant differences were found between groups receiving Omr-IgG-am compared with IVIG or saline for either the safety or efficacy endpoints.

Understanding and managing acute encephalitis

Encephalitis is an important cause of morbidity, mortality, and permanent neurologic sequelae  globally. Causes are diverse and include viral and non-viral infections of the brain as well as autoimmune processes. In the West, the autoimmune encephalitides are now more common than any single infectious cause, but, in Asia, infectious causes are still more common. In 2006, the World Health Organization coined the term "acute encephalitis syndrome", which simply means acute onset of fever with convulsions or altered consciousness or both. In 2013, the International Encephalitis Consortium set criteria for diagnosis of encephalitis on basis of clinical and laboratory features. The most important infectious cause in the West is herpes simplex virus, but globally Japanese encephalitis (JE) remains the single largest cause. Etiologic diagnosis is difficult because of the large number of agents that can cause encephalitis. Also, the responsible virus may be detectable only in the brain and is either absent or transiently found in blood or cerebrospinal fluid (CSF). Virological diagnosis is complex, expensive, and time-consuming. Different centres could make their own algorithms for investigation in accordance with the local etiologic scenarios. Magnetic resonance imaging (MRI) and electroencephalography are specific for few agents. Clinically, severity may vary widely. A severe case may manifest with fever, convulsions, coma, neurologic deficits, and death. Autoimmune encephalitis (AIE)  includes two major categories: (i) classic paraneoplastic limbic encephalitis (LE) with autoantibodies against intracellular neuronal antigens (Eg: Hu and Ma2) and (ii) new-type AIE with autoantibodies to neuronal surface or synaptic antigens (Eg: anti-N-methyl-D-aspartate receptor). AIE has prominent psychiatric manifestations: psychosis, aggression, mutism, memory loss, euphoria, or fear. Seizures, cognitive decline, coma, and abnormal movements are common. Symptoms may fluctuate rapidly. Treatment is largely supportive. Specific treatment is available for herpesvirus group and non-viral infections. Various forms of immunotherapy are used for AIE.

The direct healthcare costs attributable to West Nile virus illness in Ontario, Canada: a population-based cohort study using laboratory and health administrative data

Background

West Nile virus (WNV) is a mosquito-borne flavivirus, first detected in the Western Hemisphere in 1999 and spread across North America over the next decade. Though endemic in the most populous areas of North America, few studies have estimated the healthcare costs associated with WNV. The objective of this study was to determine direct healthcare costs attributable to WNV illness in Ontario, Canada.

Methods

We conducted a cost-of-illness study on incident laboratory confirmed and probable WNV infected subjects identified from the provincial laboratory database from Jan 1, 2002 through Dec 31, 2012. Infected subjects were linked to health administrative data and matched to uninfected subjects. We used phase-of-care methods to calculate costs for 3 phases of illness: acute infection, continuing care, and final care prior to death. Mean 10-day attributable costs were reported in 2014 Canadian dollars, per capita. Sensitivity analysis was conducted to test the impact of WNV neurologic syndromes on healthcare costs.

Results

One thousand five hundred fifty-one laboratory confirmed and probable WNV infected subjects were ascertained; 1540 (99.3%) were matched to uninfected subjects. Mean age of WNV infected subjects was 49.1 ± 18.4 years, 50.5% were female. Mean costs attributable to WNV were $1177 (95% CI: $1001, $1352) for acute infection, $180 (95% CI: $122, $238) for continuing care, $11,614 (95% CI: $5916, $17,313) for final care - acute death, and $3199 (95% CI: $1770, $4627) for final care - late death. Expected 1-year costs were $13,648, adjusted for survival. Three hundred seventeen infected subjects were diagnosed with at least one neurologic syndrome and greatest healthcare costs in acute infection were associated with encephalitis ($4710, 95% CI: $3770, $5650).

Conclusions

WNV is associated with increased healthcare resource utilization across all phases of care. High-quality studies are needed to understand the health system impact of vector-borne diseases and evaluate the cost effectiveness of novel WNV interventions.

Zoonosis: Update on Existing and Emerging Vector-Borne Illnesses in the USA

PURPOSE OF REVIEW

This review describes mosquito- and tick-borne diseases found in the Western Hemisphere. It focuses on emerging diseases and recent geographic shifts in the presence of disease vectors.

RECENT FINDINGS

Mosquito and tick vectors have become more widespread as environmental conditions have become more favorable. Zika recently has emerged as a concern for fetal anomalies. West Nile Virus has become widespread. Lyme disease and other tick-borne diseases are more prevalent in areas previously inhospitable to these ticks.

SUMMARY

Healthcare providers must consider the possibility of mosquito- and tick-borne diseases in broader geographic areas and council patients traveling to endemic areas on precautions against these diseases. Treatment for suspected cases of serious tick-borne illnesses should not be delayed pending culture results.

Acute and Delayed Deaths after West Nile Virus Infection, Texas, USA, 2002-2012

Infected patients should be closely monitored for prevention of future health problems.

Infection with West Nile virus (WNV) has a well-characterized acute disease process. However, long-term consequences are less understood. We searched death records for 4,142 residents of Texas, USA, infected with WNV during 2002–2012 and identified 557 (13%) deaths. We analyzed all-cause and cause-specific deaths after WNV infection by calculating standardized mortality ratios and using statewide mortality data. Acute-phase deaths (<90 days after symptom onset) occurred in 289 (7%) of case-patients; of those deaths, 289 (92%) were cases of West Nile neuroinvasive disease (WNND). Convalescent-phase deaths (>90 days after symptom onset) occurred in 268 (7%) of the remaining 3,853 case-patients; 210 (78%) of these deaths occurred in patients with WNND. Convalescent-phase WNND case-patients showed excess deaths from infectious and renal causes; case-patients <60 years of age had increased risk for all-cause death, specifically from renal, infectious, digestive, and circulatory causes. We provide population-level evidence of increased risk for death after WNV infection resulting in WNND.

2018 international meeting of the Global Virus Network

The Global Virus Network (GVN) was established in 2011 to strengthen research and responses to emerging viral causes of human disease and to prepare against new viral pandemics. There are now 45 GVN Centers of Excellence and 7 Affiliate laboratories in 29 countries. The 10th International GVN meeting was held from November 28–30, 2018 in Veyrier du Lac, France and was co-hosted by the two GVN Centers of Excellence, the Mérieux Foundation and the University of Veterinary Medicine Hannover (TiHo). The theme of this 10th International GVN meeting was “Eradication and control of (re-) emerging viruses”. This report highlights the recent accomplishments of GVN researchers in several important areas of medical virology, including strategies for the eradication of smallpox, measles, polio, SARS and vector-borne or zoonotic infections, emergence and intervention strategies for retroviruses and arboviruses, preparedness for outbreaks of Filo- and other hemophilic viruses, pathogenesis, impact and prevention of respiratory viruses, as well as, viruses affecting the central and peripheral nervous system. Also threats in crisis settings like refugee camps were presented.

Nonhuman primate models of human viral infections

Humans have a close phylogenetic relationship with nonhuman primates (NHPs) and share many physiological parallels, such as highly similar immune systems, with them. Importantly, NHPs can be infected with many human or related simian viruses. In many cases, viruses replicate in the same cell types as in humans, and infections are often associated with the same pathologies. In addition, many reagents that are used to study the human immune response cross-react with NHP molecules. As such, NHPs are often used as models to study viral vaccine efficacy and antiviral therapeutic safety and efficacy and to understand aspects of viral pathogenesis. With several emerging viral infections becoming epidemic, NHPs are proving to be a very beneficial benchmark for investigating human viral infections.

Health-related quality of life in persons with West Nile virus infection: a longitudinal cohort study

Background

West Nile virus (WNV) infections are predominantly asymptomatic, although almost 1% become neuroinvasive and debilitating. We describe the impact of neuroinvasive and non-neuroinvasive disease on patient health-related quality of life (HRQoL).

Methods

Short Form 36 questionnaire data came from a Canadian WNV cohort (Loeb 2008) of 154 patients followed for up to three years. We generated health utilities using the SF-6D. We calculated mean utility scores throughout follow-up and examined predictors using a linear mixed-effects model. We summarized HRQoL post-acute infection as: (i) long-term utility (mean of scores one year onward); (ii) area under the curve (AUC) one year onward. We examined predictors using beta regression. We used multiple imputation for sensitivity analysis.

Results

Mean utility scores improved from 0.59 (95% CI: 0.38, 0.93) at baseline to 0.77 (0.53, 1) at six months, before plateauing for the remaining two years. Mean long-term utility was 0.81 (0.78, 0.85) and mean AUC was 0.80 (0.76, 0.84). Patients with neuroinvasive disease had consistently worse scores than their non-neuroinvasive counterparts, with the gap nearly closed after six months. After adjusting for confounding, neuroinvasive disease was not a significant predictor of HRQoL either throughout follow-up or post-acute infection. Rather, number of comorbidities and baseline utility scores were. Sensitivity analysis showed similar findings.

Conclusions

Patients with WNV infection reported low HRQoL during acute illness, but improved rapidly by six months, regardless of neuroinvasive disease status. This is the first study reporting health utilities for WNV infection.

Electronic supplementary material

The online version of this article (10.1186/s12955-017-0787-5) contains supplementary material, which is available to authorized users.