West Nile virus infection: a pediatric perspective

New Prognostic Parameter of West Nile Virus: Platelet Distribution Width

Background: West Nile virus (WNV) infection is a viral disease caused by arboviruses. It can cause epidemics of febrile diseases and meningoencephalitis, especially at the end of the summer season. In this study, we aimed to determine the risk factors of WNV encephalitis with a case-control study of the patients followed in our clinic. Materials and Methods: Among the patients who applied to our hospital with sudden onset fever, headache, myalgia, nausea, vomiting, maculopapular rash, viral meningitis, or encephalitis findings in late summer and early autumn, those diagnosed with positive WNV PCR and antibody tests were defined as WNV cases. In the same date range, patients with clinically compatible but negative serological and PCR tests for WNV in our hospital were considered as the control group. Results: WNV infection was diagnosed in 26 of 48 patients who were examined with a preliminary diagnosis of WNV infection, and the other 22 patients were considered as the control group. A statistically significant difference was found between the two groups in C-reactive protein, procalcitonin, 1-h erythrocyte sedimentation rate, alkaline phosphatase, platelet, and platelet distribution width (PDW). PDW >17.85% indicated WNV infection with 82% sensitivity and 91% specificity. PDW percentage >17.85 increased the risk of WNV infection by 6.1 times. The power of the study was calculated as 83%. Conclusion: The most common findings in WNV cases were fever and confusion. WNV infection should be considered in the differential diagnosis in patients with fever and confusion in September and October in settlements on the migration route of birds. The percentage of PDW in whole blood examination can guide the differential diagnosis of WNV cases.

Gestational Viral Infections: Role of Host Immune System

Viral infections in pregnancy are major causes of maternal and fetal morbidity and mortality. Infections can develop in the neonate transplacentally, perinatally, or postnatally (from breast milk or other sources) and lead to different clinical manifestations, depending on the viral agent and the gestational age at exposure. Viewing the peculiar tolerogenic status which characterizes pregnancy, viruses could exploit this peculiar immunological status to spread or affect the maternal immune system, adopting several evasion strategies. In fact, both DNA and RNA virus might have a deep impact on both innate and acquired immune systems. For this reason, investigating the interaction with these pathogens and the host's immune system during pregnancy is crucial not only for the development of most effective therapies and diagnosis but mostly for prevention. In this review, we will analyze some of the most important DNA and RNA viruses related to gestational infections.

Recent Advancements in Mosquito-Borne Flavivirus Vaccine Development

Lately, the global incidence of flavivirus infection has been increasing dramatically and presents formidable challenges for public health systems around the world. Most clinically significant flaviviruses are mosquito-borne, such as the four serotypes of dengue virus, Zika virus, West Nile virus, Japanese encephalitis virus and yellow fever virus. Until now, no effective antiflaviviral drugs are available to fight flaviviral infection; thus, a highly immunogenic vaccine would be the most effective weapon to control the diseases. In recent years, flavivirus vaccine research has made major breakthroughs with several vaccine candidates showing encouraging results in preclinical and clinical trials. This review summarizes the current advancement, safety, efficacy, advantages and disadvantages of vaccines against mosquito-borne flaviviruses posing significant threats to human health.

Simple and Field Amenable Loop-Mediated Isothermal Amplification-Lateral Flow Dipstick Assay for Detection of West Nile Virus in Human Clinical Samples

AIM

West Nile encephalitis caused by infection with the West Nile virus (WNV) is endemic in many regions of the world and is a global public health threat. The aim of this report was to develop a method using colorimetry based reverse-transcription loop-mediated isothermal amplification (cRT-LAMP) and RT-LAMP combined with lateral-flow dipstick (LFD) for rapidly detecting WNV in low-infrastructure settings.

METHODS AND RESULTS

The primers for the cRT-LAMP and RT-LAMP-LFD assay were designed based on env gene of the WNV. Primers concentration, temperature, and time were optimized for cRT-LAMP and RT-LAMP-LFD. The diagnostic performance of the cRT-LAMP and RT-LAMP-LFD assay was evaluated using human serum samples from 110 patients who were clinically suspected to be infected with WNV. The RT-LAMP was performed in a heating block at 63°C for 40 minutes. The LAMP amplicons were visible in the lateral-flow dipstick within 5 minutes. The detection limit of the developed cRT-LAMP and RT-LAMP-LFD assay was 10 copies and this assay showed high degree of specificity for WNV. Compared with quantitative real-time RT-PCR assay, the kappa value of cRT-LAMP and RT-LAMP-LFD were 0.970.

CONCLUSIONS

These results showed that the newly developed WNV specific cRT-LAMP and RT-LAMP-LFD assays can be employed as an alternative method for screening of WN suspected human samples. The results revealed that the assay could potentially identify the virus without interference from human serum samples. Collectively, the all results revealed that cRT-LAMP and RT-LAMP-LFD assay offers suitable field based diagnosis of WNV.

SIGNIFICANCE AND IMPACT OF STUDY

The cRT-LAMP and LAMP-LFD platform for the detection of WNV is rapid, accurate, and simple-to-perform. Our present method has not only a short turnaround time but also avoided cross-contamination problem. Moreover, the use of simple lateral flow dipsticks broadens its application potential to the point-of-care use in resource-limited settings during outbreak situations. To the best of our knowledge this is the first report for the development of cRT-LAMP and LAMP-LFD assay for rapid, simple, specific, and sensitive detection of WNV using human clinical samples and EvaGreen dye.

West Nile and Usutu virus seroprevalence in Hungary: A nationwide serosurvey among blood donors in 2019

In Hungary, West Nile virus (WNV) has been responsible for 459 laboratory confirmed human cases between 2004 and 2019, while the first human Usutu virus (USUV) infection was confirmed only in 2018. A comprehensive serosurvey was conducted among blood donors to assess the WNV and USUV seroprevalence in 2019, one year after the largest European WNV epidemic. Altogether, 3005 plasma samples were collected and screened for WNV and USUV specific Immunoglobulin G (IgG) antibodies by Enzyme-Linked Immunosorbent Assay (ELISA). All reactive samples were further tested for tick-borne encephalitis virus IgG antibodies by ELISA. Indirect immunofluorescence test and microneutralization assay were used as confirmatory methods. Overall, the WNV seroprevalence was 4.32%, and in five blood donors USUV seropositivity was confirmed. The highest seroprevalence was measured in Central, Eastern and Southern Hungary, while the Western part of the country proved to be less affected. There was a statistically strong association between the WNV seroprevalence of 2019 and the cumulative incidence in the period of 2004 and 2019 calculated for every NUTS 3 region. The last WNV serological screening was performed in 2016 and the prevalence of anti-WNV IgG proved to be 2.19%. One year after the 2018 WNV outbreak, a significant increase in seroprevalence was observed in the Hungarian population and evidence for USUV seropositivity was also obtained. The spatial pattern of seroprevalence can support the identification of high-risk areas raising awareness of the need for increased surveillance, such as screening vector, equine, and avian populations. The communication with general practitioners and other professionals in primary health care services can support the early identification of acute human cases. Education and awareness-raising on the importance of protection against mosquito vectors amongst residents are also important parts of preventive measures.

Infectious Agents and Stroke: A Systematic Review

Introduction:

A major cause of injury and the second cause of death worldwide is stroke. Among several infectious agents considered as the risk factor of stroke, some pathogens demonstrated stronger robust associations with stroke. Proposing an accurate correlation between infectious microorganisms and stroke provides valuable information for early intervention and control of the infections.

Methods:

In this study, we searched the literature using the Web of Science, PMC/Medline via PubMed, and Scopus databases up to July 2018 without time and language restrictions. After quality assessment, 16 articles were included in the study. The whole data extraction process was independently conducted by two reviewers.

Results:

Based on the results of the studies, viruses, such as Hepatitis C virus (HCV), Hepatitis B virus (HBV), Human Immunodeficiency Virus (HIV), Herpes Simplex Virus Type-1, 2 (HSV-1, 2), Varicella-Zoster Virus (VZV or Chickenpox), and West Nile virus (WNV) seem to be common causes of ischemic stroke. Moreover, the association of other microbial categories, such as Streptococcus mutans (in bacteria), Toxocara spp. and Toxoplasma gondii (in parasites), and Rhizopus sp. (in fungi) with stroke was reported.

Conclusion:

Considering the adverse role of the above-mentioned microorganisms, it is necessary to implement some preventive measures for stroke treatment.

Extraordinary increase in West Nile virus cases and first confirmed human Usutu virus infection in Hungary, 2018

BackgroundDuring the 2018 WNV transmission season, similarly to other endemic areas in Europe, a large number of human West Nile virus (WNV) infections were reported in Hungary.AimsWe summarise the epidemiological and laboratory findings of the 2018 transmission season and expand experiences in flavivirus differential diagnostics.MethodsEvery patient with clinical suspicion of acute WNV infection was in parallel tested for WNV, tick-borne encephalitis virus and Usutu virus (USUV) by serological methods. Sera, whole blood and urine samples were also tested for the presence of viral nucleic acid.ResultsUntil the end of December 2018, 215 locally acquired and 10 imported human WNV infections were notified in Hungary. All reported cases were symptomatic; most of them exhibited neurological symptoms. In a large proportion of tested individuals, whole blood was the most appropriate sample type for viral nucleic acid detection, but because whole blood samples were not always available, testing of urine samples also extended diagnostic possibilities. In addition, the first human USUV infection was confirmed in 2018 in a patient with aseptic meningitis. Serological cross-reactions with WNV in different serological assays were experienced, but subsequent molecular biological testing and sequence analysis identified Europe lineage 2 USUV infection.ConclusionCareful interpretation and simultaneous application of different laboratory methods are necessary to avoid misdiagnosis of human USUV cases. Expansion of the laboratory-confirmed case definition criteria for detection of viral RNA in any clinical specimens to include urine samples could increase diagnostic sensitivity.

Retrospective Descriptive Analysis of West Nile Neuroinvasive Disease (WNND) in Northwest Louisiana

Aims

The aim of the study was to describe the presentation characteristics and epidemiology of WNND in Louisiana to improve future recognition of cases and decrease inappropriate antibiotic use. Settings and Design. It was a retrospective descriptive-analytic cohort study. A total of 23 patients with WNND were identified at one tertiary care hospital center in Northwest Louisiana from a retrospective chart review from January 1, 2012 to October 31, 2017.

Results

The median age was 49 years (range: 15–75) for patients with WNND. Of 23 patients diagnosed with WNND, twelve (52%) were diagnosed with encephalitis (WNE), six (26%) were diagnosed with meningitis (WNM), and five (22%) with myelitis (WNME). The common symptoms with WNND were fever in 65%, altered mental status in 61%, headache in 52%, fatigue in 43%, gastrointestinal symptoms in 43%, rigors in 30%, imbalance in 26%, rash in 9%, and seizures in 26% of patients. Most patients presented in the late summer season. The average duration of antibiotics given was six days. The average number of days from the admission to the diagnosis of WNND was nine days (3 to 16 days). Twenty-one (91%) patients survived the infection.

Conclusions

Identifying WNV infection early in its clinical course would help in decreasing inappropriate antibiotic use when patients presented with fever and meningeal symptoms. Performing WNV serology in CSF studies is critical in making the diagnosis.

Usutu Virus: An Arbovirus on the Rise

The Usutu virus (USUV) is a flavivirus that is drawing increasing attention because of its potential for emergence. First isolated in Africa, it was introduced into Europe where it caused significant outbreaks in birds, such as in Austria in 2001. Since then, its geographical distribution has rapidly expanded, with increased circulation, especially in the last few years. Similar to West Nile virus (WNV), the USUV enzootic transmission cycle involves Culex mosquitoes as vectors, and birds as amplifying reservoir hosts, with humans and other mammals likely being dead-end hosts. A similarity in the ecology of these two viruses, which co-circulate in several European countries, highlights USUV’s potential to become an important human pathogen. While USUV has had a severe impact on the blackbird population, the number of human cases remains low, with most infections being asymptomatic. However, some rare cases of neurological disease have been described, both in healthy and immuno-compromised patients. Here, we will discuss the transmission dynamics and the current state of USUV circulation in Europe.

West Nile virus infections are here! Are we prepared to face another flavivirus epidemic?

Emerging arthropod-borne viruses (arboviruses), such as chikungunya and Zika viruses, are a major threat to public health in countries like Brazil where biodiversity is high and medical care is sometimes precarious. West Nile fever is a disease caused by the West Nile Virus (WNV), an RNA virus belonging to the Flaviviridae family. It is transmitted by infected mosquitoes to numerous animals like birds, reptiles and mammals, including human and non-human primates. In the last decade, the number of reported cases of WNV infection in humans and animals has increased in the Americas. Circulation of WNV in forests and rural areas in Brazil has been detected based on serological surveys and, in 2014, the first case of West Nile fever was confirmed in a patient from Piauí State. In 2018, the virus was isolated for the first time from a horse from a rural area in the state of Espírito Santo presenting with a neurological disorder; this raises the possibility that other cases of WNV encephalitis may have occurred without clinical recognition and without laboratory diagnosis by specific assays. The imminent WNV outbreak poses a challenge for Brazilian clinicians and researchers. In this review, we summarize the basic biological and ecological characteristics of this virus and the clinical presentation and treatment of febrile illnesses caused by WNV. We also discuss the epidemiological aspects, prophylaxis of WNV infections, and monitoring strategies that could be applied in the possibility of a WNV outbreak in Brazil.

Pediatric West Nile Virus-Associated Neuroinvasive Disease: A Review of the Literature

Over the past two decades, West Nile virus has become the most common arbovirus in North America, leading to several outbreaks and infecting thousands of people. Mosquitos help transmit the virus in the majority of cases, but transmission occurs via blood transfusions, organ transplantation, and possibly pregnancy and breastfeeding. While most infected patients experience mild to no symptoms, thousands of West Nile virus-associated neuroinvasive cases have been reported in the United States, with over 700 cases occurring in children from 2003 to 2016. Neuroinvasive disease presents as meningitis, encephalitis, or acute flaccid paralysis, and carries a high likelihood of poor outcome, including severe neurological disability or death. To date, no pharmacologic treatment has proven effective. Therapeutic clinical trials have not been successfully completed due to the sporadic nature of viral outbreaks and resultant poor study enrollment. Although older age and chronic disease are risk factors for neuroinvasive West Nile virus disease in adults, the specific factors that influence the risk in pediatric populations have not been fully elucidated. This review summarizes the most recent literature regarding West Nile virus-associated neuroinvasive disease, especially as it pertains to the pediatric population. Moreover, the review describes the epidemiology, clinical, laboratory, and radiographic findings, and outlines the various therapies that have been trialed and potential future research directions.

Zoonotic Viral Diseases of Equines and Their Impact on Human and Animal Health

INTRODUCTION

Zoonotic diseases are the infectious diseases that can be transmitted to human beings and vice versa from animals either directly or indirectly. These diseases can be caused by a range of organisms including bacteria, parasites, viruses and fungi. Viral diseases are highly infectious and capable of causing pandemics as evidenced by outbreaks of diseases like Ebola, Middle East Respiratory Syndrome, West Nile, SARS-Corona, Nipah, Hendra, Avian influenza and Swine influenza.

EXPALANTION

Many viruses affecting equines are also important human pathogens. Diseases like Eastern equine encephalitis (EEE), Western equine encephalitis (WEE), and Venezuelan-equine encephalitis (VEE) are highly infectious and can be disseminated as aerosols. A large number of horses and human cases of VEE with fatal encephalitis have continuously occurred in Venezuela and Colombia. Vesicular stomatitis (VS) is prevalent in horses in North America and has zoonotic potential causing encephalitis in children. Hendra virus (HeV) causes respiratory and neurological disease and death in man and horses. Since its first outbreak in 1994, 53 disease incidents have been reported in Australia. West Nile fever has spread to many newer territories across continents during recent years.It has been described in Africa, Europe, South Asia, Oceania and North America. Japanese encephalitis has expanded horizons from Asia to western Pacific region including the eastern Indonesian archipelago, Papua New Guinea and Australia. Rabies is rare in horses but still a public health concern being a fatal disease. Equine influenza is historically not known to affect humans but many scientists have mixed opinions. Equine viral diseases of zoonotic importance and their impact on animal and human health have been elaborated in this article.

CONCLUSION

Equine viral diseases though restricted to certain geographical areas have huge impact on equine and human health. Diseases like West Nile fever, Hendra, VS, VEE, EEE, JE, Rabies have the potential for spread and ability to cause disease in human. Equine influenza is historically not known to affect humans but some experimental and observational evidence show that H3N8 influenza virus has infected man. Despite our pursuit of understanding the complexity of the vector-host-pathogen mediating disease transmission, it is not possible to make generalized predictions concerning the degree of impact of disease emergence. A targeted, multidisciplinary effort is required to understand the risk factors for zoonosis and apply the interventions necessary to control it.

Prevalence of chronic comorbidities in dengue fever and West Nile virus: A systematic review and meta-analysis

Background

Flavivirus diseases such as dengue fever (DENV), West Nile virus (WNV), Zika and yellow fever represent a substantial global public health concern. Preexisting chronic conditions such as cardiovascular diseases, diabetes, obesity, and asthma were thought to predict risk of progression to severe infections.

Objective

We aimed to quantify the frequency of chronic comorbidities in flavivirus diseases to provide an estimate for their prevalence in severe and non-severe infections and examine whether chronic diseases contribute to the increased risk of severe viral expression.

Methods

We conducted a comprehensive search in PubMed, Ovid MEDLINE(R), Embase and Embase Classic and grey literature databases to identify studies reporting prevalence estimates of comorbidities in flavivirus diseases. Study quality was assessed with the risk of bias tool. Age-adjusted odds ratios (ORs) were estimated for severe infection in the presence of chronic comorbidities.

Results

We identified 65 studies as eligible for inclusion for DENV (47 studies) and WNV (18 studies). Obesity and overweight (i.e., BMI> 25 kg/m², prevalence: 24.5%, 95% CI: 18.6–31.6%), hypertension (17.1%, 13.3–21.8%) and diabetes (13.3%, 9.3–18.8%) were the most prevalent comorbidities in DENV. However, hypertension (45.0%, 39.1–51.0%), diabetes (24.7%, 20.2–29.8%) and heart diseases (25.6%, 19.5–32.7%) were the most prevalent in WNV. ORs of severe flavivirus diseases were about 2 to 4 in infected patients with comorbidities such as diabetes, hypertension and heart diseases. The small number of studies in JEV, YFV and Zika did not permit estimating the prevalence of comorbidities in these infections.

Conclusion

Higher prevalence of chronic comorbidities was found in severe cases of flavivirus diseases compared to non-severe cases. Findings of the present study may guide public health practitioners and clinicians to evaluate infection severity based on the presence of comorbidity, a critical public health measure that may avert severe disease outcome given the current dearth of clear prevention practices for some flavivirus diseases.

Studying the effects of emerging infections on the fetus: Experience with West Nile and Zika viruses

Emerging infections have the potential to produce adverse effects on the pregnant woman or her fetus; however, studying these effects is often challenging. We review our experiences with investigating the prenatal effects of two mosquito‐borne infections that emerged in the past 2 decades, West Nile virus (WNV) and Zika virus. Concerns regarding teratogenicity were raised about both viruses; Zika virus has been confirmed to be teratogenic, while WNV appears not to increase the risk for adverse outcomes, although teratogenicity has not been excluded. Study designs used to examine the effects of both viruses include case reports and series, pregnancy registries, and cohort studies. Case–control studies and birth defects surveillance systems are being used to study the effects during pregnancy of Zika virus, but not the effects of WNV, because a specific phenotype was observed among infants with congenital Zika infection, but not among infants with congenital WNV infection. Experimental data that demonstrated that Zika virus was neurotropic have also been useful because they provided biologic plausibility for Zika virus's teratogenic effects: these findings were consistent with observations in congenitally infected infants. Challenges encountered with studies to evaluate the effects of these infections include the broad range of possible adverse outcomes, the inability to include all infected pregnant women in studies because many infections are asymptomatic, and the difficulty with interpretation of diagnostic testing of infants (WNV and Zika) and pregnant women (Zika). This review might be helpful to guide future studies of the effects of emerging infections during pregnancy. Birth Defects Research 109:363–371, 2017. © 2017 Wiley Periodicals, Inc.

West Nile Virus Infection

Although long recognized as a human pathogen, West Nile virus (WNV) emerged as a significant public health problem following its introduction and spread across North America. Subsequent years have seen a greater understanding of all aspects of this viral infection. The North American epidemic resulted in a further understanding of the virology, pathogenesis, clinical features, and epidemiology of WNV infection. Approximately 80% of human WNV infections are asymptomatic. Most symptomatic people experience an acute systemic febrile illness; less than 1% of infected people develop neuroinvasive disease, which typically manifests as meningitis, encephalitis, or anterior myelitis resulting in acute flaccid paralysis. Older age is associated with more severe illness and higher mortality; other risk factors for poor outcome have been challenging to identify. In addition to natural infection through mosquito bites, transfusion- and organ transplant-associated infections have occurred. Since there is no definitive treatment for WNV infection, protection from mosquito bites and other preventative measures are critical. WNV has reached an endemic pattern in North America, but the future epidemiologic pattern is uncertain.

Visual Detection of West Nile Virus Using Reverse Transcription Loop-Mediated Isothermal Amplification Combined with a Vertical Flow Visualization Strip

West Nile virus (WNV) causes a severe zoonosis, which can lead to a large number of casualties and considerable economic losses. A rapid and accurate identification method for WNV for use in field laboratories is urgently needed. Here, a method utilizing reverse transcription loop-mediated isothermal amplification combined with a vertical flow visualization strip (RT-LAMP-VF) was developed to detect the envelope (E) gene of WNV. The RT-LAMP-VF assay could detect 10² copies/μl of an WNV RNA standard using a 40 min amplification reaction followed by a 2 min incubation of the amplification product on the visualization strip, and no cross-reaction with other closely related members of the Flavivirus genus was observed. The assay was further evaluated using cells and mouse brain tissues infected with a recombinant rabies virus expressing the E protein of WNV. The assay produced sensitivities of 10^1.5 TCID₅₀/ml and 10^1.33 TCID₅₀/ml for detection of the recombinant virus in the cells and brain tissues, respectively. Overall, the RT-LAMP-VF assay developed in this study is rapid, simple and effective, and it is therefore suitable for clinical application in the field.

West Nile Virus Infection in the Central Nervous System

West Nile virus (WNV), a neurotropic single-stranded flavivirus has been the leading cause of arboviral encephalitis worldwide.  Up to 50% of WNV convalescent patients in the United States were reported to have long-term neurological sequelae.  Neither antiviral drugs nor vaccines are available for humans.  Animal models have been used to investigate WNV pathogenesis and host immune response in humans.  In this review, we will discuss recent findings from studies in animal models of WNV infection, and provide new insights on WNV pathogenesis and WNV-induced host immunity in the central nervous system.

An Update on the Hazards and Risks of Forensic Anthropology, Part II: Field and Laboratory Considerations

This paper focuses on potential hazards and risks to forensic anthropologists while working in the field and laboratory in North America. Much has changed since Galloway and Snodgrass published their seminal article addressing these issues. The increased number of forensic practitioners combined with new information about potential hazards calls for an updated review of these pathogens and chemicals. Discussion of pathogen hazards (Brucella, Borrelia burgdorferi, Yersinia pestis, Clostridium tetani and West Nile virus) includes important history, exposure routes, environmental survivability, early symptoms, treatments with corresponding morbidity and mortality rates, and decontamination measures. Additionally, data pertaining to the use of formaldehyde in the laboratory environment have resulted in updated safety regulations, and these are highlighted. These data should inform field and laboratory protocols. The hazards of working directly with human remains are discussed in a companion article, "An Update on the Hazards and Risks of Forensic Anthropology, Part I: Human Remains."

West Nile virus infection in children

West Nile virus (WNV) is an emerging flavivirus responsible for an increasing number of outbreaks of neuroinvasive disease in North America, Europe, and neighboring countries. Almost all WNV infections in humans are transmitted through the bite of infected mosquitoes. Transmission during pregnancy and through breastfeeding has been reported, but the risk seems to be very low. West Nile disease in children is less common (1-5% of all WNV cases) and associated with milder symptoms and better outcome than in elderly individuals, even though severe neuroinvasive disease and death have been reported also among children. However, the incidence of WNV infection and disease in children is probably underestimated and the disease spectrum is not fully understood because of lack of reporting and underdiagnosis in children. Infection is diagnosed by detection of WNV-specific antibodies in serum and WNV RNA in plasma and urine. Since no effective WNV-specific drugs are available, therapy is mainly supportive.

Virus and Immune-Mediated Encephalitides: Epidemiology, Diagnosis, Treatment, and Prevention

Virus encephalitis remains a major cause of acute neurological dysfunction and permanent disability among children worldwide. Although some disorders, such as measles encephalomyelitis, subacute sclerosing panencephalitis, and varicella-zoster virus-associated neurological conditions, have largely disappeared in resource-rich regions because of widespread immunization programs, other disorders, such as herpes simplex virus encephalitis, West Nile virus-associated neuroinvasive disease, and nonpolio enterovirus-induced disorders of the nervous system, cannot be prevented. Moreover, emerging viral disorders pose new, potential threats to the child's nervous system. This review summarizes current information regarding the epidemiology of virus encephalitis, the diagnostic methods available to detect central nervous system infection and identify viral pathogens, and the available treatments. The review also describes immune-mediated disorders, including acute disseminated encephalomyelitis and N-methyl-D-aspartate receptor antibody encephalitis, conditions that mimic virus encephalitis and account for a substantial proportion of childhood encephalitis.

The global ecology and epidemiology of West Nile virus

Since its initial isolation in Uganda in 1937 through the present, West Nile virus (WNV) has become an important cause of human and animal disease worldwide. WNV, an enveloped virus of the genus Flavivirus, is naturally maintained in an enzootic cycle between birds and mosquitoes, with occasional epizootic spillover causing disease in humans and horses. The mosquito vectors for WNV are widely distributed worldwide, and the known geographic range of WNV transmission and disease has continued to increase over the past 77 years. While most human infections with WNV are asymptomatic, severe neurological disease may develop resulting in long-term sequelae or death. Surveillance and preventive measures are an ongoing need to reduce the public health impact of WNV in areas with the potential for transmission.

Developmental outcomes in young children born to mothers with West Nile illness during pregnancy

BACKGROUND

West Nile virus (WNV) infection is associated with acute morbidity and mortality in adults and children. Information on the effects of maternal WNV illness during pregnancy on early childhood development is limited. This study was designed to examine the relationship between maternal WNV illness during pregnancy and birth and developmental outcomes at age 3 years.

METHODS

Mother-child participants were identified using a national surveillance registry for women with WNV illness during pregnancy. Maternal and infant health data and relevant family characteristics were obtained through medical record reviews and maternal questionnaires. All infants received ophthalmologic examinations. Child development was evaluated at age 3 years using the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III).

RESULTS

As a group, the children's (N = 11) birth weight, head circumference, and infant ophthalmologic examination results were within age expectations; one child was born preterm (gestational age 36 weeks). Mean (SD) age at the time of Bayley-III testing was 36.7 (3.8) months. The group's mean performance on the Bayley-III was at or above age level in all domains, but one child showed a mild delay in the Adaptive domain. The variability observed in this sample (1/53 [1.9%] Domain scores < -2.0 SDs) was consistent with expectations based upon the distribution of Bayley-III Domain scores in the general population.

CONCLUSION

Maternal WNV infection does not appear to be associated with global developmental delays in young children. These results are preliminary, however, and require confirmation in future research.

Neuroinvasive arboviral disease in the United States: 2003 to 2012

OBJECTIVE

To describe the epidemiologic and clinical syndromes associated with pediatric neuroinvasive arboviral infections among children in the United States from 2003 through 2012.

METHODS

We reviewed data reported by state health departments to ArboNET, the national arboviral surveillance system, for 2003 through 2012. Children (<18 years) with neuroinvasive arboviral infections (eg, meningitis, encephalitis, or acute flaccid paralysis) were included. Demographic, clinical syndrome, outcome, geographic, and temporal data were analyzed for all cases.

RESULTS

During the study period, 1217 cases and 22 deaths due to pediatric neuroinvasive arboviral infection were reported from the 48 contiguous states. La Crosse virus (665 cases; 55%) and West Nile virus (505 cases; 41%) were the most common etiologies identified. Although less common, Eastern equine encephalitis virus (30 cases; 2%) resulted in 10 pediatric deaths. La Crosse virus primarily affected younger children, whereas West Nile virus was more common in older children and adolescents. West Nile virus disease cases occurred throughout the country, whereas La Crosse and the other arboviruses were more focally distributed.

CONCLUSIONS

Neuroinvasive arboviral infections were an important cause of pediatric disease from 2003 through 2012. Differences in the epidemiology and clinical disease result from complex interactions among virus, vector, host, and the environment. Decreasing the morbidity and mortality from these agents depends on vector control, personal protection to reduce mosquito and tick bites, and blood donor screening. Effective surveillance is critical to inform clinicians and public health officials about the epidemiologic features of these diseases and to direct prevention efforts.

Clinical manifestations and outcomes of West Nile virus infection

Since the emergence of West Nile virus (WNV) in North America in 1999, understanding of the clinical features, spectrum of illness and eventual functional outcomes of human illness has increased tremendously. Most human infections with WNV remain clinically silent. Among those persons developing symptomatic illness, most develop a self-limited febrile illness. More severe illness with WNV (West Nile neuroinvasive disease, WNND) is manifested as meningitis, encephalitis or an acute anterior (polio) myelitis. These manifestations are generally more prevalent in older persons or those with immunosuppression. In the future, a more thorough understanding of the long-term physical, cognitive and functional outcomes of persons recovering from WNV illness will be important in understanding the overall illness burden.

West Nile virus state of the art report of MALWEST Project

During the last three years Greece is experiencing the emergence of West Nile virus (WNV) epidemics. Within this framework, an integrated surveillance and control programme (MALWEST project) with thirteen associate partners was launched aiming to investigate the disease and suggest appropriate interventions. One out of seven work packages of the project is dedicated to the State of the Art report for WNV. Three expert working groups on humans, animals and mosquitoes were established. Medical databases (PubMed, Scopus) were searched together with websites: e.g., WHO, CDC, ECDC. In total, 1,092 relevant articles were initially identified and 258 of them were finally included as references regarding the current knowledge about WNV, along with 36 additional sources (conference papers, reports, book chapters). The review is divided in three sections according to the fields of interest: (1) WNV in humans (epidemiology, molecular characteristics, transmission, diagnosis, treatment, prevention, surveillance); (2) WNV in animals (epidemiological and transmission characteristics concerning birds, horses, reptiles and other animal species) and (3) WNV in mosquitoes (control, surveillance). Finally, some examples of integrated surveillance programmes are presented. The introduction and establishment of the disease in Greece and other European countries further emphasizes the need for thorough research and broadening of our knowledge on this viral pathogen.

A review of vaccine approaches for West Nile virus

The West Nile virus (WNC) first appeared in North America in 1999. The North American lineages of WNV were characterized by the presence of neuroinvasive and neurovirulent strains causing disease and death in humans, birds and horses. The 2012 WNV season in the United States saw a massive spike in the number of neuroinvasive cases and deaths similar to what was seen in the 2002–2003 season, according to the West Nile virus disease cases and deaths reported to the CDC by year and clinical presentation, 1999–2012, by ArboNET (Arboviral Diseases Branch, Centers for Disease Control and Prevention). In addition, the establishment and recent spread of lineage II WNV virus strains into Western Europe and the presence of neurovirulent and neuroinvasive strains among them is a cause of major concern. This review discusses the advances in the development of vaccines and biologicals to combat human and veterinary West Nile disease.

The role of Australian mosquito species in the transmission of endemic and exotic West Nile virus strains

Recent epidemic activity and its introduction into the Western Hemisphere have drawn attention to West Nile virus (WNV) as an international public health problem. Of particular concern has been the ability for the virus to cause outbreaks of disease in highly populated urban centers. Incrimination of Australian mosquito species is an essential component in determining the receptivity of Australia to the introduction and/or establishment of an exotic strain of WNV and can guide potential management strategies. Based on vector competence experiments and ecological studies, we suggest candidate Australian mosquito species that would most likely be involved in urban transmission of WNV, along with consideration of the endemic WNV subtype, Kunjin. We then examine the interaction of entomological factors with virological and vertebrate host factors, as well as likely mode of introduction, which may influence the potential for exotic WNV to become established and be maintained in urban transmission cycles in Australia.

Quadraplex qRT-PCR assay for the simultaneous detection of Eastern equine encephalitis virus and West Nile virus

In order to increase testing throughput and reduce cost, we developed a multiplex real-time assay that identifies both Eastern equine encephalitis virus and West Nile virus. The assay allows for the screening for the presence of both the nonstructural and envelope genes of both viruses simultaneously allowing for confirmatory testing to be done in a single assay. We utilized newly designed primers and probes, each labeled with a unique fluorescent label allowing for differentiation using an ABI 7500 real-time PCR machine. The use of Quanta Biosciences qScript XLT One-Step RT-qPCR® Toughmix allowed for a quadraplex assay without loss of sensitivity when compared to the previously run singleplex reaction as seen with viral RNA PFU control dilution series. There was no cross reactivity between the viruses within the reaction, and upon utilization of the assay during surveillance, there was no cross reactivity with other historically encountered arthropod-borne viruses. The results from the quantitative Reverse Transcriptase - Polymerase Chain Reaction were comparable to those achieved by cell culture which was performed on a subset of the field mosquito pools screened during the 2012 surveillance season. The multiplex assay resulted in savings in both time and resources for the lab and faster turn-around of results.

West Nile Virus: biology, transmission, and human infection

West Nile Virus was introduced into the Western Hemisphere during the late summer of 1999 and has been causing significant and sometimes severe human diseases since that time. This article briefly touches upon the biology of the virus and provides a comprehensive review regarding recent discoveries about virus transmission, virus acquisition, and human infection and disease.

West Nile virus in north-eastern Italy, 2011: entomological and equine IgM-based surveillance to detect active virus circulation

Since 2008, West Nile Virus (WNV) has expanded its range in several Italian regions, and its yearly recurrence suggests the virus may have become endemic in some areas. In 2011, a new plan based also on the detection of IgM antibodies was implemented in the north-eastern Italian regions of Veneto and Friuli Venezia Giulia, aiming to early detect WNV infections in areas where the virus had already circulated during the previous summers, and in adjacent zones. From July to November 2011, 1880 sera from 521 equine premises were screened by a commercial IgM capture ELISA. Mosquitoes were captured by CDC-CO2 traps at 61 locations in the two regions. Collected mosquitoes were identified, pooled by species/date/location and examined by real-time RT-PCR and sequencing. Passive surveillance was carried out on clinically affected horses and non-migratory wild birds found dead. IgM sero-positive equines were detected in 19 holdings, five in the area with WNV circulation (AWC) and 14 in the surveillance area (SA); 10 more horse premises tested positive to further serological controls within 4 km of the positive holdings. A total of 85,398 mosquitoes of 15 species were collected and 2732 pools examined. Five Culex pipiens pools tested positive for the presence of WNV. Passive surveillance on non-migratory wild birds allowed detection of the virus only in one found dead collared dove (Streptopelia decaocto), of 82 birds sampled. The WNV belonged to the lineage 2, which had been isolated for the first time in Italy earlier in 2011. By the first week of October, nine human cases had been confirmed in the same area. The implementation of a protocol combining IgM screening of horses with surveillance on mosquito vectors proved to be valuable for early detecting WNV circulation.

West Nile virus: A re-emerging pathogen revisited

West Nile virus (WNV), a flavivirus of the Flaviviridae family, is maintained in nature in an enzootic transmission cycle between avian hosts and ornithophilic mosquito vectors, although the virus occasionally infects other vertebrates. WNV causes sporadic disease outbreaks in horses and humans, which may result in febrile illness, meningitis, encephalitis and flaccid paralysis. Until recently, its medical and veterinary health concern was relatively low; however, the number, frequency and severity of outbreaks with neurological consequences in humans and horses have lately increased in Europe and the Mediterranean basin. Since its introduction in the Americas, the virus spread across the continent with worrisome consequences in bird mortality and a considerable number of outbreaks among humans and horses, which have resulted in the largest epidemics of neuroinvasive WNV disease ever documented. Surprisingly, its incidence in human and animal health is very different in Central and South America, and the reasons for it are not yet understood. Even though great advances have been obtained lately regarding WNV infection, and although efficient equine vaccines are available, no specific treatments or vaccines for human use are on the market. This review updates the most recent investigations in different aspects of WNV life cycle: molecular virology, transmission dynamics, host range, clinical presentations, epidemiology, ecology, diagnosis, control, and prevention, and highlights some aspects that certainly require further research.

West Nile virus (WNV) transmission routes in the murine model: intrauterine, by breastfeeding and after cannibal ingestion

Since its first detection in New York in 1999, West Nile virus (WNV) has already caused over 1000 human deaths in the U.S. Although the virus is usually transmitted by mosquito bites; other routes, such as intrauterine and breastfeeding, have been occasionally reported in humans. To investigate alternative routes of WNV transmission, mice were inoculated during gestation and after delivery, and offspring from infected and non-infected mothers were interchanged and nursed as foster babies. Intrauterine and breastfeeding transmission was confirmed after WNV detection, by quantitative RT-PCR and viral culture infectivity, in babies born to infected mothers and in newborns that were nursed by mothers infected after delivery. All infected mothers, either experimentally or after cannibal ingestion of infected fostered babies, succumbed to the disease, as did most of their nursed babies. These results indicate that WNV is efficiently transmitted by vertical routes (intrauterine and lactation) and after cannibal ingestion of infected animals.

An examination of the effect of landscape pattern, land surface temperature, and socioeconomic conditions on WNV dissemination in Chicago

This paper developed an approach by the synthesis of remote sensing, landscape metrics, and statistical methods to examine the effects of landscape pattern, land surface temperature, and socioeconomic conditions on the spread of West Nile virus (WNV) caused by mosquitoes and animal hosts in Chicago, USA. Land use/land cover and land surface temperature images were derived from Terra's Advanced Spaceborne Thermal Emission and Reflection Radiometer imagery. An analytical procedure using landscape metrics was developed, applying configuration analysis of landscape patterns in the study area. The positive reports of mosquitoes and animal hosts for WNV in fall, 2001-2006, were collected from the Cook County Public Health Department. Forty-nine municipalities were found to have WNV-positive records in mosquitoes and animal hosts in fall 2004. Socioeconomic data were obtained from the 2000 US Census. Statistical analysis was applied to WNV data in fall 2004 to identify the relationship between potential predictors and WNV spread. As a result, landscape factors, such as landscape aggregation index and the urban areas and areas of grass and water, showed strong correlations with the WNV-positive records. Socioeconomic conditions, such as the population over 65 years old, also showed a strong correlation with WNV-positive records. Thermal conditions of water showed a less but still considerable correlation to WNV-positive records. This research offers an opportunity to explore the effects of landscape pattern, land surface temperature, and socioeconomic conditions on the spread of WNV caused by mosquitoes and animal hosts. Results can contribute to public health and environmental management in the study area.

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.

West Nile virus disease in children, United States, 1999-2007

BACKGROUND

Although West Nile virus (WNV) disease has occurred predominantly among adults in the United States, children are also susceptible. Epidemiological data describing WNV disease in children are limited.

METHODS

We described the epidemiological features of WNV disease among children (<18 years of age) reported to the Centers for Disease Control and Prevention from 1999 through 2007 and compared features of pediatric and adult West Nile neuroinvasive disease (WNND).

RESULTS

Of 1478 pediatric WNV cases reported from 1999 through 2007, 443 (30%) were classified as WNND, 1009 (68%) were classified as West Nile fever, and 26 (2%) were of unknown clinical presentation. Three WNND cases were fatal. The vast majority of reported case subjects (92%) had onset of illness between July and September. Children accounted for only 4% of all of the WNND case subjects reported from 1999 to 2007, with a median annual incidence of 0.07 case subjects per 100 000 children (range: 0.00-0.19 case subjects). In children and younger adults WNND most often manifested as meningitis, in contrast to the predominance of encephalitis among older adults with WNND. The geographic distribution and temporal trends were of pediatric and adult WNND.

CONCLUSIONS

The epidemiological characteristics of WNV disease in children are similar to adult case subjects; however, WNND is more likely to manifest as meningitis in children than in older adults. WNV should be considered in the differential diagnosis for pediatric patients presenting with febrile illness, meningitis, encephalitis, or acute flaccid paralysis, particularly during seasonal outbreaks in endemic areas.

The impact of social amplification and attenuation of risk and the public reaction to mad cow disease in Canada

Following the detection of bovine spongiform encephalopathy (BSE) in Canada, and subsequently in the United States, confidence in the safety of beef products remained high. Consumers actually increased their consumption of beef slightly after the news of an increased risk from mad cow disease, which has been interpreted as public support for beef farmers and confidence in government regulators. The Canadian public showed a markedly different reaction to the news of domestic BSE than the furious and panicked responses observed in the United Kingdom, Germany, and Japan. Using the social amplification of risk framework, we show that, while other countries displayed social amplification of risk, Canada experienced a social attenuation of risk. The attenuated reaction in Canada toward mad cow disease and increased human health risks from variant Creutzfeldt-Jakob disease (vCJD) was due to the social context at the time when BSE was discovered domestically. Mortality, morbidity, and psychosocial impacts resulting from other major events such as severe acute respiratory syndrome (SARS), West Nile virus (WNV), and the U.S.-Iraq war made the theoretical risks of BSE and vCJD a lower priority, reducing its concern as a risk issue.

Mosquito-borne diseases

Despite centuries of control efforts, mosquito-borne diseases are flourishing worldwide. With a disproportionate effect on children and adolescents, these conditions are responsible for substantial global morbidity and mortality. Malaria kills more than 1 million children annually, chiefly in sub-Saharan Africa. Dengue virus has expanded its range over the past several decades, following its principal vector, Aedes aegypti, back into regions from which it was eliminated in the mid-20th century and causing widespread epidemics of hemorrhagic fever. West Nile virus has become endemic throughout the Americas in the past 10 years, while chikungunya virus has emerged in the Indian Ocean basin and mainland Asia to affect millions. Japanese encephalitis virus, too, has expanded its range in the Indian subcontinent and Australasia, mainly affecting young children. Filariasis, on the other hand, is on the retreat, the subject of a global eradication campaign. Efforts to limit the effect of mosquito-borne diseases in endemic areas face the twin challenges of controlling mosquito populations and delivering effective public health interventions. Travelers to areas endemic for mosquito-borne diseases require special advice on mosquito avoidance, immunizations, and malaria prophylaxis.

Recombinant vesicular stomatitis virus-based west Nile vaccine elicits strong humoral and cellular immune responses and protects mice against lethal challenge with the virulent west Nile virus strain LSU-AR01

Vesicular stomatitis virus (VSV) has been extensively utilized as a viral vector system for the induction of protective immune responses against a variety of pathogens. We constructed recombinant VSVs specifying either the Indiana or Chandipura virus G glycoprotein and expressing the West Nile virus (WNV) envelope (E) glycoprotein. Mice were intranasally vaccinated using a prime (Indiana)-boost (Chandipura) immunization approach and challenged with the virulent WNV-LSU-AR01. Ninety-percent (9 of 10) of the vaccinated mice survived as compared to 10% of the mock-vaccinated mice after WNV lethal challenge. Histopathological examination of brain tissues revealed neuronal necrosis in mock-vaccinated mice but not in vaccinated mice, and vaccinated, but not mock-vaccinated mice developed a strong neutralizing antibody response against WNV. Extensive immunological analysis using polychromatic flow cytometry staining revealed that vaccinated, but not mock-vaccinated mice developed robust cellular immune responses as evidenced by up-regulation of CD4⁺ CD154⁺ IFNγ⁺ T cells in vaccinated, but not mock-vaccinated mice. Similarly, vaccinated mice developed robust E-glycoprotein-specific CD8⁺ T cell immune responses as evidenced by the presence of a high percentage of CD8⁺ CD62L^low IFNγ⁺ cells. In addition, a sizeable population of CD8⁺ CD69⁺ cells was detected indicating E-specific activation of mature T cells and CD4⁺ CD25⁺ CD127^low T regulatory (T reg) cells were down-regulated. These results suggest that VSV-vectored vaccines administered intranasally can efficiently induce protective humoral and cellular immune responses against WNV infections.

West nile poliomyelitis in a 7-year-old child

West Nile poliomyelitis is a well-described neurologic manifestation of West Nile viral infection in adults. However, few reports have described this manifestation in children infected with West Nile virus. We describe a 7-year-old boy who developed West Nile poliomyelitis with flaccid paralysis of his left leg. Electrodiagnostic testing and radiologic imaging confirmed anterior horn cell injury. We report on his course clinically and electrodiagnostically over 20 months.

[Children arthropod bites protective measures: insecticides and repellents]

Vector transmitted diseases are often a serious threat for child health, especially for children traveller in tropical regions. Few arthropod borne diseases are preventable by immunization or chimioprophylaxis. Prevention of most of them is based on personal protection against arthropod bites. The evidence of its efficacy has been established by the use of impregnated bed nets, impregnated clothes with permethrin or mosquito repellent which reduced significantly child malaria morbidity and mortality in endemic countries. These personal protective measures are able to minimize arthropod bites and prevent Chikungunya infection, dengue fever and Lyme disease. The choice of a repellent among the commercialised products need to be efficacy and safety evidence based. This article propose to raise this issue and to give pragmatic recommendations, with a focus to children below 30 months who are at a high toxicological risk. Severity of these diseases allowed to use potentially toxic repellents if misused.