Virology, pathology, and clinical manifestations of West Nile virus disease

The historical ecological background of West Nile virus in Portugal indicates One Health opportunities

West Nile (WNV) is a zoonotic arbovirus with an expanding geographical range and epidemic activity in Europe. Not having yet experienced a human-associated epidemic, Portugal remains an outlier in the Mediterranean basin. In this study, we apply ecological niche modelling informed by WNV historical evidence and a multitude of environmental variables from across Portugal. We identify that ecological backgrounds compatible with WNV historical circulation are mostly restricted to the south, characterized by a warmer and drier climate, high avian diversity, specific avian species and land types. We estimate WNV ecological suitability across the country, identifying overlaps with the distributions of the three relevant hosts (humans, birds, equines) for public and animal health. From this, we propose a category-based spatial framework providing first of a kind valuable insights for WNV surveillance in Portugal under the One Health nexus. We forecast that near future climate trends alone will contribute to pushing adequate WNV ecological suitability northwards, towards regions with higher human density. This unique perspective on the past, present and future ecology of WNV addresses existing national knowledge gaps, enhances our understanding of the evolving emergence of WNV, and offers opportunities to prepare and respond to the first human-associated epidemic in Portugal.

Denial

A 51-year-old man presented with decreased vision, fever, confusion, headaches, agitation, nausea, vomiting and diarrhea. Magnetic resonance imaging of the brain demonstrated bilateral T2 hyperintense lesions in the region of the mesial temporal lobe and optic radiations. There was a predominantly polymorphonuclear leukocyte pleocytosis in the cerebrospinal fluid (CSF) with hyperproteinorachia. A meningoencephalitis was diagnosed. Intravenous fluorescein angiography (IVFA) demonstrated a multifocal chorioretinitis that was in a linear pattern in the left eye. CSF enzyme-linked immunosorbent assay was positive for West Nile virus (WNV) IgM. We review the clinical manifestations of WNV disease and highlight the value of IVFA in determining the diagnosis.

Dengue virus infection and neurological manifestations: an update

Dengue virus is a flavivirus transmitted by the mosquitoes, Aedes aegypti and Aedes albopictus. Dengue infection by all four serotypes (DEN 1 to 4) is endemic globally in regions with tropical and subtropical climates, with an estimated 100-400 million infections annually. Among those hospitalized, the mortality is about 1%. Neurological involvement has been reported to be about 5%. The spectrum of neurological manifestations spans both the peripheral and central nervous systems. These manifestations could possibly be categorized into those directly related to dengue infection, i.e. acute and chronic encephalitis, indirect complications leading to dengue encephalopathy, and post-infectious syndrome due to immune-mediated reactions, and manifestations with uncertain mechanisms, such as acute transverse myelitis, acute cerebellitis and myositis. The rising trend in global dengue incidence calls for attention to a more explicit definition of each neurological manifestation for more accurate epidemiological data. The actual global burden of dengue infection with neurological manifestation is essential for future planning and execution of strategies, especially in the development of effective antivirals and vaccines against the dengue virus. In this article, we discuss the recent findings of different spectrums of neurological manifestations in dengue infection and provide an update on antiviral and vaccine development and their challenges.

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.

A Spatially Resolved and Environmentally Informed Forecast Model of West Nile Virus in Coachella Valley, California

West Nile virus (WNV) is the most significant arbovirus in the United States in terms of both morbidity and mortality. West Nile exists in a complex transmission cycle between avian hosts and the arthropod vector, Culex spp. mosquitoes. Human spillover events occur when humans are bitten by an infected mosquito and predicting these rates of infection and therefore the risk to humans may be associated with fluctuations in environmental conditions. In this study, we evaluate the hydrological and meteorological drivers associated with mosquito biology and viral development to determine if these associations can be used to forecast seasonal mosquito infection rates with WNV in the Coachella Valley of California. We developed and tested a spatially resolved ensemble forecast model of the WNV mosquito infection rate in the Coachella Valley using 17 years of mosquito surveillance data and North American Land Data Assimilation System-2 environmental data. Our multi-model inference system indicated that the combination of a cooler and dryer winter, followed by a wetter and warmer spring, and a cooler than normal summer was most predictive of the prevalence of West Nile positive mosquitoes in the Coachella Valley. The ability to make accurate early season predictions of West Nile risk has the potential to allow local abatement districts and public health entities to implement early season interventions such as targeted adulticiding and public health messaging before human transmission occurs. Such early and targeted interventions could better mitigate the risk of WNV to humans.

Immunization with different recombinant West Nile virus envelope proteins induces varying levels of serological cross-reactivity and protection from infection

Introduction

West Nile Virus (WNV) is a zoonotic flavivirus transmitted by mosquitoes. Especially in the elderly or in immunocompromised individuals an infection with WNV can lead to severe neurological symptoms. To date, no human vaccine against WNV is available. The Envelope (E) protein, located at the surface of flaviviruses, is involved in the invasion into host cells and is the major target for neutralizing antibodies and therefore central to vaccine development. Due to their close genetic and structural relationship, flaviviruses share highly conserved epitopes, such as the fusion loop domain (FL) in the E protein, that are recognized by cross-reactive antibodies. These antibodies can lead to enhancement of infection with heterologous flaviviruses, which is a major concern for potential vaccines in areas with co-circulation of different flaviviruses, e.g. Dengue or Zika viruses.

Material

To reduce the potential of inducing cross-reactive antibodies, we performed an immunization study in mice using WNV E proteins with either wild type sequence or a mutated FL, and WNV E domain III which does not contain the FL at all.

Results and discussion

Our data show that all antigens induce high levels of WNV-binding antibodies. However, the level of protection against WNV varied, with the wildtype E protein inducing full, the other antigens only partial protection. On the other hand, serological cross-reactivity to heterologous flaviviruses was significantly reduced after immunization with the mutated E protein or domain III as compared to the wild type version. These results have indications for choosing antigens with the optimal specificity and efficacy in WNV vaccine development.

The Ongoing Epidemic of West Nile Virus in Greece: The Contribution of Biological Vectors and Reservoirs and the Importance of Climate and Socioeconomic Factors Revisited

Emerging infectious diseases have inflicted a significant health and socioeconomic burden upon the global population and governments worldwide. West Nile virus, a zoonotic, mosquito-borne flavivirus, was originally isolated in 1937 from a febrile patient in the West Nile Province of Uganda. It remained confined mainly to Africa, the Middle East, and parts of Europe and Australia until 1999, circulating in an enzootic mosquito-bird transmission cycle. Since the beginning of the 21st century, a new, neurotropic, more virulent strain was isolated from human outbreaks initially occurring in North America and later expanding to South and South-eastern Europe. Since 2010, when the first epidemic was recorded in Greece, annual incidence has fluctuated significantly. A variety of environmental, biological and socioeconomic factors have been globally addressed as potential regulators of the anticipated intensity of the annual incidence rate; circulation within the zoonotic reservoirs, recruitment and adaptation of new potent arthropod vectors, average winter and summer temperatures, precipitation during the early summer months, and socioeconomic factors, such as the emergence and progression of urbanization and the development of densely populated areas in association with insufficient health policy measures. This paper presents a review of the biological and socioenvironmental factors influencing the dynamics of the epidemics of West Nile virus (WNV) cases in Greece, one of the highest-ranked European countries in terms of annual incidence. To date, WNV remains an unpredictable opponent as is also the case with other emerging infectious diseases, forcing the National Health systems to develop response strategies, control the number of infections, and shorten the duration of the epidemics, thus minimizing the impact on human and material resources.

Ecological Niche Modeling of Aedes and Culex Mosquitoes: A Risk Map for Chikungunya and West Nile Viruses in Zambia

The circulation of both West Nile Virus (WNV) and Chikungunya Virus (CHIKV) in humans and animals, coupled with a favorable tropical climate for mosquito proliferation in Zambia, call for the need for a better understanding of the ecological and epidemiological factors that govern their transmission dynamics in this region. This study aimed to examine the contribution of climatic variables to the distribution of Culex and Aedes mosquito species, which are potential vectors of CHIKV, WNV, and other arboviruses of public-health concern. Mosquitoes collected from Lusaka as well as from the Central and Southern provinces of Zambia were sorted by species within the Culex and Aedes genera, both of which have the potential to transmit viruses. The MaxEnt software was utilized to predict areas at risk of WNV and CHIKV based on the occurrence data on mosquitoes and environmental covariates. The model predictions show three distinct spatial hotspots, ranging from the high-probability regions to the medium- and low-probability regions. Regions along Lake Kariba, the Kafue River, and the Luangwa Rivers, as well as along the Mumbwa, Chibombo, Kapiri Mposhi, and Mpika districts were predicted to be suitable habitats for both species. The rainfall and temperature extremes were the most contributing variables in the predictive models.

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.

Development of recombinant West Nile virus expressing mCherry reporter protein

West Nile virus (WNV) is transmitted to humans and animals by a mosquito and enters the central nervous system, leading to lethal encephalitis. Reporter viruses expressing fluorescent proteins enable detection of infected cells in vitro and in vivo, facilitating evaluation of the dynamics of viral infection, and the development of diagnostic or therapeutic methods. In this study, we developed a method for production of a recombinant replication-competent WNV expressing mCherry fluorescent protein. The expression of mCherry was observed in viral antigen-positive cells in vitro and in vivo, but the growth of the reporter WNV was reduced as compared to the parental WNV. The expression of mCherry was stable during 5 passages in reporter WNV-infected culture cells. Neurological symptoms were observed in mice inoculated intracranially with the reporter WNV. The reporter WNV expressing mCherry will facilitate research into WNV replication in mouse brains.

Patterns of West Nile Virus in the Northeastern United States Using Negative Binomial and Mechanistic Trait-Based Models

West Nile virus (WNV) primarily infects birds and mosquitoes but has also caused over 2,000 human deaths, and >50,000 reported human cases in the United States. Expected numbers of WNV neuroinvasive cases for the present were described for the Northeastern United States, using a negative binomial model. Changes in temperature-based suitability for WNV due to climate change were examined for the next decade using a temperature-trait model. WNV suitability was generally expected to increase over the next decade due to changes in temperature, but the changes in suitability were generally small. Many, but not all, populous counties in the northeast are already near peak suitability. Several years in a row of low case numbers is consistent with a negative binomial, and should not be interpreted as a change in disease dynamics. Public health budgets need to be prepared for the expected infrequent years with higher-than-average cases. Low-population counties that have not yet had a case are expected to have similar probabilities of having a new case as nearby low-population counties with cases, as these absences are consistent with a single statistical distribution and random chance.

Treatment with Granulocyte-Macrophage Colony-Stimulating Factor Reduces Viral Titers in the Brains of West Nile Virus-Infected Mice and Improves Survival

West Nile virus (WNV) is the leading cause of epidemic arboviral encephalitis in the United States. As there are currently no proven antiviral therapies or licensed human vaccines, understanding the neuropathogenesis of WNV is critical for rational therapeutic design. In WNV-infected mice, the depletion of microglia leads to enhanced viral replication, increased central nervous system (CNS) tissue injury, and increased mortality, suggesting that microglia play a critical role in protection against WNV neuroinvasive disease. To determine if augmenting microglial activation would provide a potential therapeutic strategy, we administered granulocyte-macrophage colony-stimulating factor (GM-CSF) to WNV-infected mice. Recombinant human GM-CSF (rHuGMCSF) (sargramostim [Leukine]) is an FDA-approved drug used to increase white blood cells following leukopenia-inducing chemotherapy or bone marrow transplantation. Daily treatment of both uninfected and WNV-infected mice with subcutaneous injections of GM-CSF resulted in microglial proliferation and activation as indicated by the enhanced expression of the microglia activation marker ionized calcium binding adaptor molecule 1 (Iba1) and several microglia-associated inflammatory cytokines, including CCL2 (C-C motif chemokine ligand 2), interleukin 6 (IL-6), and IL-10. In addition, more microglia adopted an activated morphology as demonstrated by increased sizes and more pronounced processes. GM-CSF-induced microglial activation in WNV-infected mice was associated with reduced viral titers and apoptotic activity (caspase 3) in the brains of WNV-infected mice and significantly increased survival. WNV-infected ex vivo brain slice cultures (BSCs) treated with GM-CSF also showed reduced viral titers and caspase 3 apoptotic cell death, indicating that GM-CSF specifically targets the CNS and that its actions are not dependent on peripheral immune activity. Our studies suggest that stimulation of microglial activation may be a viable therapeutic approach for the treatment of WNV neuroinvasive disease. IMPORTANCE Although rare, WNV encephalitis poses a devastating health concern, with few treatment options and frequent long-term neurological sequelae. Currently, there are no human vaccines or specific antivirals against WNV infections, so further research into potential new therapeutic agents is critical. This study presents a novel treatment option for WNV infections using GM-CSF and lays the foundation for further studies into the use of GM-CSF as a treatment for WNV encephalitis as well as a potential treatment for other viral 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.

Serosurvey in Two Dengue Hyperendemic Areas of Costa Rica Evidence Active Circulation of WNV and SLEV in Peri-Domestic and Domestic Animals and in Humans

Costa Rica harbors several flaviviruses, including Dengue (DENV), Zika (ZIKV), West Nile virus (WNV), and Saint Louis encephalitis virus (SLEV). While DENV and ZIKV are hyperendemic, previous research indicates restricted circulation of SLEV and WNV in animals. SLEV and WNV seroprevalence and high transmission areas have not yet been measured. To determine the extents of putative WNV and SLEV circulation, we sampled peri-domestic and domestic animals, humans, and mosquitoes in rural households located in two DENV and ZIKV hyperendemic regions during the rainy and dry seasons of 2017-2018 and conducted plaque reduction neutralization test assay for serology (PRNT) and RT-PCR for virus detection. In Cuajiniquil, serological evidence of WNV and SLEV was found in equines, humans, chickens, and wild birds. Additionally, five seroconversion events were recorded for WNV (2 equines), SLEV (1 human), and DENV-1 (2 humans). In Talamanca, WNV was not found, but serological evidence of SLEV circulation was recorded in equines, humans, and wild birds. Even though no active viral infection was detected, the seroconversion events recorded here indicate recent circulation of SLEV and WNV in these two regions. This study thus provides clear-cut evidence for WNV and SLEV presence in these areas, and therefore, they should be considered in arboviruses differential diagnostics and future infection prevention campaigns.

Re-Introduction of West Nile Virus Lineage 1 in Senegal from Europe and Subsequent Circulation in Human and Mosquito Populations between 2012 and 2021

West Nile virus (WNV) is a virus of the Japanese encephalitis antigenic complex and belongs to the family Flaviviridae of the genus flavivirus. The virus can cause infection in humans which in most cases is asymptomatic, however symptomatic cases exist and the disease can be severe causing encephalitis and meningoencephalitis. The virus is maintained in an enzootic cycle involving mosquitoes and birds, humans and other mammals such as horses can be accidental hosts. A mosquito-based arbovirus surveillance system and the sentinel syndromic surveillance network (4S) have been in place since 1988 and 2015 respectively, to better understand the transmission dynamics of arboviruses including WNV in Senegal. Arthropod and human samples have been collected from the field and analysed at Institut Pasteur de Dakar using different methods including RT-PCR, ELISA, plaque reduction neutralization test and viral isolation. RT-PCR positive samples have been analysed by Next Generation Sequencing. From 2012 to 2021, 7912 samples have been analysed and WNV positive cases have been detected, 20 human cases (19 IgM and 1 RT-PCR positive cases) and 41 mosquito pools. Phylogenetic analyzes of the sequences of complete genomes obtained showed the circulation of lineage 1a, with all these recent strains from Senegal identical to each other and very close to strains isolated from horse in France in 2015, Italy and Spain. Our data showed lineage 1a endemicity in Senegal as previously described, with circulation of WNV in humans and mosquitoes. Phylogenetic analyzes carried out with the genome sequences obtained also revealed exchanges of WNV strains between Europe and Senegal which could be possible via migratory birds. The surveillance systems that have enabled the detection of WNV in humans and arthropods should be extended to animals in a one-health approach to better prepare for global health threats.

West Nile Disease Symptoms and Comorbidities: A Systematic Review and Analysis of Cases

West Nile virus (WNV) is a mosquito-borne flavivirus that has emerged as a major cause of viral encephalitis and meningitis, rarely leading to death. Several risk factors have been discussed in the past concerning the severity of the disease, while few reports have focused on precipitating conditions that determine of WNV-related death. Studies on cohorts of patients suffering of West Nile disease (WND) usually encompass low numbers of deceased patients as a result of the rarity of the event. In this systematic review and critical analysis of 428 published case studies and case series, we sought to evaluate and highlight critical parameters of WND-related death. We summarized the symptoms, comorbidities, and treatment strategies related to WND in all published cases of patients that included clinical features. Symptoms such as altered mental status and renal problems presented increased incidence among deceased patients, while these patients presented increased cerebrospinal fluid (CSF) glucose. Our analysis also highlights underestimated comorbidities such as pulmonary disease to act as precipitating conditions in WND, as they were significantly increased amongst deceased patients. CSF glucose and the role of pulmonary diseases need to be revaluated either retrospectively or prospectively in WND patient cohorts, as they may be linked to increased mortality risk.

Modelling the temperature suitability for the risk of West Nile Virus establishment in European Culex pipiens populations

Increases in temperature and extreme weather events due to global warming can create an environment that is beneficial to mosquito populations, changing and possibly increasing the suitable geographical range for many vector-borne diseases. West Nile Virus (WNV) is a flavivirus, maintained in a mosquito-avian host cycle that is usually asymptomatic but can cause primarily flu-like symptoms in human and equid accidental hosts. In rare circumstances, serious disease and death are possible outcomes for both humans and horses. The main European vector of WNV is the Culex pipiens mosquito. This study examines the effect of environmental temperature on WNV establishment in Europe via Culex pipiens populations through use of a basic reproduction number ( R 0 ${R_0}$ ) model. A metric of thermal suitability derived from R 0 ${R_0}$ was developed by collating thermal responses of different Culex pipiens traits and combining them through use of a next-generation matrix. WNV establishment was determined to be possible between 14°C and 34.3°C, with the optimal temperature at 23.7°C. The suitability measure was plotted against monthly average temperatures in 2020 and the number of months with high suitability mapped across Europe. The average number of suitable months for each year from 2013 to 2019 was also calculated and validated with reported equine West Nile fever cases from 2013 to 2019. The widespread thermal suitability for WNV establishment highlights the importance of European surveillance for this disease and the need for increased research into mosquito and bird distribution.

West Nile Virus Seroprevalence and Cross-Neutralization in Sera from Eastern and Central Sudan

Objectives: In regions with co-existing flaviviruses, the diagnosis of previous West Nile virus (WNV) infections is challenging due to cross-reacting antibodies. The aim of the study was to determine the frequency of previous WNV infections in sera from three Sudanese states by excluding potentially dengue virus (DENV) and ZIKV cross-reacting sera and to determine the percentage of WNV cross-neutralizing sera from individuals with previous DENV infection. Methods: Serum samples from Kassala, North Kordofan, and Red Sea state were screened for antibodies against DENV by ELISA. Sera without DENV antibodies (N = 106) and a matched set of sera with DENV antibodies (N = 108) was selected. In all blood samples the frequency of WNV-neutralizing antibodies and the antibody titers were measured with microplate neutralization assays. DENV and Zika virus (ZIKV) microplate neutralization assays were performed with all WNV neutralizing sera of the DENV negative group. Results: A fraction of 30.2% of the DENV antibody negative sera neutralized WNV. The seroprevalence increased with age from 9.5% to 41.7%. Men and women were equally affected. The percentage of DENV positive sera that neutralized WNV was 83.3%. DENV positive sera had higher WNV neutralization titers than DENV negative sera. Conclusions: A significant fraction of the DENV antibody negative sera from three regions in Sudan showed serologic evidence of previous WNV infection. In comparison, the large majority of DENV antibody positive sera had WNV neutralizing antibodies. Studies are needed to identify clinical cases of WNV infection and to determine whether individuals with cross-neutralizing antibodies are protected from WNV disease.

Retrospective Investigation in Horses with Encephalitis Reveals Unnoticed Circulation of West Nile Virus in Brazil

During these past years, several studies have provided serological evidence regarding the circulation of West Nile virus (WNV) in Brazil. Despite some reports, much is still unknown regarding the genomic diversity and transmission dynamics of this virus in the country. Recently, genomic monitoring activities in horses revealed the circulation of WNV in several Brazilian regions. These findings on the paucity of genomic data reinforce the need for prompt investigation of WNV infection in horses, which may precede human cases of encephalitis in Brazil. Thus, in this study, we retrospectively screened 54 suspicious WNV samples collected between 2017 and 2020 from the spinal cord and brain of horses with encephalitis and generated three new WNV genomes from the Ceará and Bahia states, located in the northeastern region of Brazil. The Bayesian reconstruction revealed that at least two independent introduction events occurred in Brazil. The first introduction event appears to be likely related to the North American outbreak, and was estimated to have occurred in March 2013.The second introduction event appears to have occurred in September 2017 and appears to be likely related to the South American outbreak. Together, our results reinforce the importance of increasing the priority of WNV genomic monitoring in equines with encephalitis in order to track the dispersion of this emerging pathogen through the country.

West Nile Virus Seroprevalence in Manisa Province: A Population-based Study

Objective

West Nile Virus (WNV), which causes widespread outbreaks in different parts of the world, is a risk to public health in Turkey, too. Community-based study data are needed to identify measures against possible outbreaks. This study aimed to determine the seroprevalence of community-based WNV in Manisa and to investigate the relationship between sociodemographic and socioeconomic variables.

Methods

We included individuals older than two years of age (N=1,317,917) registered in the Manisa Province Family Medicine Information System. Selected participants (n=1233) were determined by a simple random sampling method. Specific IgG antibodies against WNV were investigated in serum samples using a commercial ELISA test (Euroimmun, Germany). The relationship between age, gender, location, education and income level, occupation, population density, altitude, the location of the toilet in the house, and the presence of hypertension, diabetes mellitus and cardiovascular disease variables were analyzed by chi-square, Fisher's exact test and t-test. Adjusted odds ratio (OR) with95% confidence interval (CI) for each variable were calculated by the logistic regression method to explain potential risks.

Results

WNV IgG antibodies were detected in 47 (3.8%) sera samples by ELISA. Seroprevalence was significantly correlated with independent variables of advanced age, presence of hypertension, diabetes mellitus and cardiovascular disease, low level of education and income, living in low altitude areas and the location of the toilet. In multivariate analysis; age (every one-year increase) (OR:1.05; 95% CI:1.02-1.07; p <0.001), equivalent annual income per capita below 3265 TL (OR:3.21; 95% CI: 1.53-6.73; p=0.002), and living areas below 132 meters altitude (OR=3.21; 95% CI 1.26-8.15; p=0.014) were found to be the risk factors for WNV seropositivity.

Conclusion

In Manisa province, WNV IgG seroprevalence was detected as 3.8% with ELISA method. Older age, low income and living in regions with a low altitude were found to be associated with increased seropositivity significantly.

Depletion of Microglia in an Ex Vivo Brain Slice Culture Model of West Nile Virus Infection Leads to Increased Viral Titers and Cell Death

West Nile virus (WNV) is a major cause of viral encephalitis in the United States. WNV infection of the brain leads to neuroinflammation characterized by activation of microglia, the resident phagocytic cells of the central nervous system (CNS). In this study, depletion of CNS microglia using the CSF1R antagonist PLX5622 increased the viral load in the brain and decreased the survival of mice infected with WNV (strain TX02). PLX5622 was also used in ex vivo brain slice cultures (BSCs) to investigate the role of intrinsic neuroinflammatory responses during WNV infection. PLX5622 effectively depleted microglia (>90% depletion) from BSCs resulting in increased viral titers (3 to 4-fold increase in PLX5622-treated samples) and enhanced virus-induced caspase 3 activity and cell death. Microglia depletion did not result in widespread alterations in cytokine and chemokine production in either uninfected or WNV infected BSCs. The results of this study demonstrated how microglia contribute to limiting viral growth and preventing cell death in WNV infected BSCs but were not required for the cytokine/chemokine response to WNV infection. This study highlighted the importance of microglia in the protection from neuroinvasive WNV infection and demonstrated that microglia responses were independent of WNV-induced peripheral immune responses. IMPORTANCE WNV infections of the CNS are rare but can have devastating long-term effects. There are currently no vaccines or specific antiviral treatments, so a better understanding of the pathogenesis and immune response to this virus is crucial. Previous studies have shown microglia to be important for protection from WNV, but more work is needed to fully comprehend the impact these cells have on neuroinvasive WNV infections. This study used PLX5622 to eliminate microglia in an ex vivo brain slice culture (BSC) model to investigate the role of microglia during a WNV infection. The use of BSCs provided a system in which immune responses innate to the CNS could be studied without interference from peripheral immunity. This study will allow for a better understanding of the complex nature of microglia during viral infections and will likely impact the development of new therapeutics that target microglia.

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.

Effects of ivermectin treatment of backyard chickens on mosquito dynamics and West Nile virus transmission

Background

Vector control strategies typically rely on pesticides to target mosquitoes involved in enzootic and zoonotic transmission of West Nile virus (WNV). Nevertheless, increasing insecticide resistance and a desire to reduce pesticide usage provide the impetus for developing alternative strategies. Ivermectin (IVM), an antiparasitic drug which is widely used in human and veterinary medicine, is a potential alternative for targeted control because Culex mosquitoes experience increased mortality following ingestion of IVM in bloodmeals.

Methodology/Principal findings

We conducted a randomized field trial to investigate the impact of treating backyard chicken flocks with IVM in urban neighborhoods across Davis, California on mosquito populations and WNV transmission dynamics. We observed a significant reduction in WNV seroconversions in treated vs. untreated chickens, suggesting a reduction in WNV transmission intensity around treated flocks. We also detected a reduction in parity rates of Cx. tarsalis near treated vs. untreated flocks and increased mortality in wild mosquitoes following a bloodmeal on treated chickens (IVM serum concentration > 5ng/mL) vs. chickens with IVM serum concentrations < 5 ng/mL. However, we did not find a significant difference in abundance or infection prevalence in mosquitoes between treatment groups associated with the reductions in seroconversions. Mosquito immigration from surrounding larval habitat, relatively low WNV activity in the study area, and variable IVM serum concentrations likely contributed to uncertainty about the impact.

Conclusions/Significance

Taken together, our results point to a reduction in WNV transmission due to the impact of IVM on Culex mosquito populations and support the ongoing investigation of oral administration of IVM to wild birds for local control of WNV transmission, although further work is needed to optimize dosing and understand effects on entomological endpoints.

Current mosquito control strategies aimed to prevent pathogen transmission to humans have limited ability to target mosquitoes involved in amplification and spillover transmission of pathogens like West Nile virus (WNV). Additionally, growing prevalence of insecticide resistance in mosquito populations limit the efficacy of these insecticide-based control strategies. Ivermectin (IVM) provides an alternative avenue for control by increasing the mortality of mosquitoes that ingest this drug in bloodmeals. Therefore, IVM treatment of avian species that account for the majority of mosquito bloodmeals during the WNV transmission season could be an effective control strategy. Building on pilot studies indicating the efficacy and feasibility of IVM-deployment for WNV control, we performed a randomized field trial to investigate the impact of IVM-treatment of backyard chickens on local population dynamics of Culex mosquitoes and WNV transmission. We were able to link changes in mosquito populations to reduction in WNV transmission, as measured by chicken seroconversions, through IVM-induced mortality in mosquitoes. However, further work is needed to identify the impact of treatment on mosquito abundance and infection prevalence to fully attribute observed changes to IVM administration. Overall, our results support IVM treatment as a potentially effective alternative to insecticide-based vector control strategies and one that can be used to target WNV transmission on the local scale.

Plant-Derived Recombinant Vaccines against Zoonotic Viruses

Emerging and re-emerging zoonotic diseases cause serious illness with billions of cases, and millions of deaths. The most effective way to restrict the spread of zoonotic viruses among humans and animals and prevent disease is vaccination. Recombinant proteins produced in plants offer an alternative approach for the development of safe, effective, inexpensive candidate vaccines. Current strategies are focused on the production of highly immunogenic structural proteins, which mimic the organizations of the native virion but lack the viral genetic material. These include chimeric viral peptides, subunit virus proteins, and virus-like particles (VLPs). The latter, with their ability to self-assemble and thus resemble the form of virus particles, are gaining traction among plant-based candidate vaccines against many infectious diseases. In this review, we summarized the main zoonotic diseases and followed the progress in using plant expression systems for the production of recombinant proteins and VLPs used in the development of plant-based vaccines against zoonotic viruses.

West Nile virus transmission potential in Portugal

It is unclear whether West Nile virus (WNV) circulates endemically in Portugal. Despite the country’s adequate climate for transmission, Portugal has only reported four human WNV infections so far. We performed a review of WNV-related data (1966–2020), explored mosquito (2016–2019) and land type distributions (1992–2019), and used climate data (1981–2019) to estimate WNV transmission suitability in Portugal. Serological and molecular evidence of WNV circulation from animals and vectors was largely restricted to the south. Land type and climate-driven transmission suitability distributions, but not the distribution of WNV-capable vectors, were compatible with the North-South divide present in serological and molecular evidence of WNV circulation. Our study offers a comprehensive, data-informed perspective and review on the past epidemiology, surveillance and climate-driven transmission suitability of WNV in Portugal, highlighting the south as a subregion of importance. Given the recent WNV outbreaks across Europe, our results support a timely change towards local, active surveillance.

Lourenço et al. review historical data and quantify the transmission potential of West Nile virus in Portugal. They report a North-South divide in infection patterns, a higher ecological capacity in the south, and an increasing positive effect of climate change over the last 40 years.

Serological differentiation of West Nile virus and Usutu virus induced antibodies by envelope proteins with modified cross-reactive epitopes

West Nile virus (WNV) and Usutu virus (USUV) are mosquito-borne viruses belonging to the Japanese encephalitis virus serocomplex within the genus Flavivirus. Due to climate change and the expansion of mosquito vectors, flaviviruses are becoming endemic in increasing numbers of countries. WNV infections are reported with symptoms ranging from mild fever to severe neuro invasive disease. Until now, only a few USUV infections have been reported in humans, mostly with mild symptoms. The serological diagnosis and differentiation between flavivirus infections in general and between WNV and USUV in particular are challenging due the high degree of cross-reacting antibodies, especially of those directed against the conserved fusion loop (FL) domain of the envelope (E) protein. We have previously shown that E proteins containing four amino acid mutations in and near the FL strongly reduce the binding of cross-reactive antibodies leading to diagnostic technologies with improved specificities. Here, we expanded the technology to USUV and analyzed the differentiation of USUV and WNV induced antibodies in humans. IgG ELISAs modified by an additional competition step with the heterologous antigen resulted in overall specificities of 93.94% for WNV Equad and 92.75% for USUV Equad. IgM antibodies against WNV could be differentiated from USUV IgM in a direct comparison using both antigens. The data indicate the potential of the system to diagnose antigenically closely related flavivirus infections. This article is protected by copyright. All rights reserved.

West Nile Virus Chorioretinitis in the Presence of Negative Cerebrospinal Fluid Polymerase Chain Reaction Results

Purpose:

This work aims to evaluate the utility of nucleic acid amplification testing (NAAT) and serology in confirming West Nile Virus (WNV) infection in patients with suspected WNV chorioretinitis.

Methods:

A retrospective cross-sectional study was conducted of a cluster of patients who presented to the Retina Service of Massachusetts Eye and Ear between September and October 2018.

Results:

Three patients were identified with classic WNV chorioretinitis lesions with negative cerebrospinal fluid NAAT and positive serum serology findings. The diagnosis of WNV chorioretinitis was made based on the appearance of the fundus lesions and the presence of characteristic findings on fluorescein angiography as previously described in the literature.

Conclusions:

This report highlights 3 unique cases of WNV chorioretinitis in which NAAT of cerebrospinal fluid failed to identify WNV as the inciting agent. These cases stress the importance of serum serologic testing in diagnosing WNV infection.

Intrinsic Innate Immune Responses Control Viral Growth and Protect against Neuronal Death in an Ex Vivo Model of West Nile Virus-Induced Central Nervous System Disease

Recruitment of immune cells from the periphery is critical for controlling West Nile virus (WNV) growth in the central nervous system (CNS) and preventing subsequent WNV-induced CNS disease. Neuroinflammatory responses, including the release of proinflammatory cytokines and chemokines by CNS cells, influence the entry and function of peripheral immune cells that infiltrate the CNS. However, these same cytokines and chemokines contribute to tissue damage in other models of CNS injury. Rosiglitazone is a peroxisome proliferator-activated receptor gamma (PPARγ) agonist that inhibits neuroinflammation. We used rosiglitazone in WNV-infected ex vivo brain slice cultures (BSC) to investigate the role of neuroinflammation within the CNS in the absence of peripheral immune cells. Rosiglitazone treatment inhibited WNV-induced expression of proinflammatory chemokines and cytokines, interferon beta (IFN-β), and IFN-stimulated genes (ISG) and also decreased WNV-induced activation of microglia. These decreased neuroinflammatory responses were associated with activation of astrocytes, robust viral growth, increased activation of caspase 3, and increased neuronal loss. Rosiglitazone had a similar effect on in vivo WNV infection, causing increased viral growth, tissue damage, and disease severity in infected mice, even though the number of infiltrating peripheral immune cells was higher in rosiglitazone-treated, WNV-infected mice than in untreated, infected controls. These results indicate that local neuroinflammatory responses are capable of controlling viral growth within the CNS and limiting neuronal loss and may function to keep the virus in check prior to the infiltration of peripheral immune cells, limiting both virus- and immune-mediated neuronal damage. IMPORTANCE West Nile virus is the most common cause of epidemic encephalitis in the United States and can result in debilitating CNS disease. There are no effective vaccines or treatments for WNV-induced CNS disease in humans. The peripheral immune response is critical for protection against WNV CNS infections. We now demonstrate that intrinsic immune responses also control viral growth and limit neuronal loss. These findings have important implications for developing new therapies for WNV-induced CNS disease.

Mosquito-Borne Viral Pathogens Detected in Zambia: A Systematic Review

Emerging and re-emerging mosquito-borne viral diseases are a threat to global health. This systematic review aimed to investigate the available evidence of mosquito-borne viral pathogens reported in Zambia. A search of literature was conducted in PubMed and Google Scholar for articles published from 1 January 1930 to 30 June 2020 using a combination of keywords. Eight mosquito-borne viruses belonging to three families, Togaviridae, Flaviviridae and Phenuiviridae were reported. Three viruses (Chikungunya virus, Mayaro virus, Mwinilunga virus) were reported among the togaviruses whilst four (dengue virus, West Nile virus, yellow fever virus, Zika virus) were among the flavivirus and only one virus, Rift Valley fever virus, was reported in the Phenuiviridae family. The majority of these mosquito-borne viruses were reported in Western and North-Western provinces. Aedes and Culex species were the main mosquito-borne viral vectors reported. Farming, fishing, movement of people and rain patterns were among factors associated with mosquito-borne viral infection in Zambia. Better diagnostic methods, such as the use of molecular tools, to detect the viruses in potential vectors, humans, and animals, including the recognition of arboviral risk zones and how the viruses circulate, are important for improved surveillance and design of effective prevention and control measures.

West Nile Virus in the State of Ceará, Northeast Brazil

In June 2019, a horse with neurological disorder was diagnosed with West Nile virus (WNV) in Boa Viagem, a municipality in the state of Ceará, northeast Brazil. A multi-institutional task force coordinated by the Brazilian Ministry of Health was deployed to the area for case investigation. A total of 513 biological samples from 78 humans, 157 domestic animals and 278 free-ranging wild birds, as well as 853 adult mosquitoes of 22 species were tested for WNV by highly specific serological and/or molecular tests. No active circulation of WNV was detected in vertebrates or mosquitoes by molecular methods. Previous exposure to WNV was confirmed by seroconversion in domestic birds and by the detection of specific neutralizing antibodies in 44% (11/25) of equids, 20.9% (14/67) of domestic birds, 4.7% (13/278) of free-ranging wild birds, 2.6% (2/78) of humans, and 1.5% (1/65) of small ruminants. Results indicate that not only equines but also humans and different species of domestic animals and wild birds were locally exposed to WNV. The detection of neutralizing antibodies for WNV in free-ranging individuals of abundant passerine species suggests that birds commonly found in the region may have been involved as amplifying hosts in local transmission cycles of WNV.

Frequency of Zika Virus Immunoglobulin M Antibody in Persons with West Nile Virus Infection

West Nile virus (WNV) and Zika virus (ZIKV) are mosquito-borne viruses in the family Flaviviridae. Residents in, and travelers to, areas where the viruses are circulating are at risk for infection, and both viruses can cause an acute febrile illness. Given known cross-reactivity in flavivirus serologic assays, it is possible a patient with acute WNV infection could be misdiagnosed as having ZIKV infection if appropriate testing is not conducted. To understand how frequently persons with WNV infection have detectable cross-reactive ZIKV immunoglobulin M (IgM) antibody, we used archived serum samples from patients in the United States with recent WNV infection confirmed by a microsphere-based immunoassay test for IgM antibody and neutralizing antibody testing. Samples were tested for ZIKV IgM antibody with the Centers for Disease Control and Prevention (CDC) ZIKV IgM antibody capture enzyme-linked immunosorbent assay. Among 153 sera from patients with acute WNV infection, the ZIKV IgM antibody result was positive in 56 (37%; 95% confidence interval [CI] 29-44%) and equivocal in 28 (18%; 95% CI 13-25%). With 55% of samples having cross-reactive antibodies, it is important for health care providers to request appropriate testing based on the most likely cause of a patient's possible arboviral infection considering their clinical symptoms and signs, travel history, and place of residence. For cases where the epidemiology does not support the preliminary IgM findings, confirmatory neutralizing antibody testing should be performed. These measures will avoid an incorrect diagnosis of ZIKV infection, based on cross-reactive antibodies, in a person truly infected with WNV.

West Nile Virus in Brazil

Background: West Nile virus (WNV) was first sequenced in Brazil in 2019, when it was isolated from a horse in the Espírito Santo state. Despite multiple studies reporting serological evidence suggestive of past circulation since 2004, WNV remains a low priority for surveillance and public health, such that much is still unknown about its genomic diversity, evolution, and transmission in the country. Methods: A combination of diagnostic assays, nanopore sequencing, phylogenetic inference, and epidemiological modeling are here used to provide a holistic overview of what is known about WNV in Brazil. Results: We report new genetic evidence of WNV circulation in southern (Minas Gerais, São Paulo) and northeastern (Piauí) states isolated from equine red blood cells. A novel, climate-informed theoretical perspective of the potential transmission of WNV across the country highlights the state of Piauí as particularly relevant for WNV epidemiology in Brazil, although it does not reject possible circulation in other states. Conclusion: Our output demonstrates the scarceness of existing data, and that although there is sufficient evidence for the circulation and persistence of the virus, much is still unknown on its local evolution, epidemiology, and activity. We advocate for a shift to active surveillance, to ensure adequate preparedness for future epidemics with spill-over potential to humans.

Competition between Usutu virus and West Nile virus during simultaneous and sequential infection of Culex pipiens mosquitoes

Usutu virus (USUV) and West Nile virus (WNV) are closely related mosquito-borne flaviviruses that are mainly transmitted between bird hosts by vector mosquitoes. Infections in humans are incidental but can cause severe disease. USUV is endemic in large parts of Europe, while WNV mainly circulates in Southern Europe. In recent years, WNV is also frequently detected in Northern Europe, thereby expanding the area where both viruses co-circulate. However, it remains unclear how USUV may affect the future spread of WNV and the likelihood of human co-infection. Here we investigated whether co-infections with both viruses in cell lines and their primary mosquito vector, Culex pipiens, affect virus replication and transmission dynamics. We show that USUV is outcompeted by WNV in mammalian, avian and mosquito cells during co-infection. Mosquitoes that were exposed to both viruses simultaneously via infectious blood meal displayed significantly reduced USUV transmission compared to mosquitoes that were only exposed to USUV (from 15% to 3%), while the infection and transmission of WNV was unaffected. In contrast, when mosquitoes were pre-infected with USUV via infectious blood meal, WNV transmission was significantly reduced (from 44% to 17%). Injection experiments established the involvement of the midgut in the observed USUV-mediated WNV inhibition. The competition between USUV and WNV during co-infection clearly indicates that the chance of concurrent USUV and WNV transmission via a single mosquito bite is low. The competitive relation between USUV and WNV may impact virus transmission dynamics in the field and affect the epidemiology of WNV in Europe.

Vector-borne diseases and tourism in Iran: Current issues and recommendations

Iran is one of the largest countries in the Middle East with lots of historical and natural attractions. This country has always been considered to be one of the most important tourist destinations in the world. Several important vector-borne diseases have been reported from different parts of the country. Thus, having comprehensive and adequate knowledge about the main vector-borne diseases in Iran and their high-risk areas are really important. In this review, different provinces of Iran have been studied in terms of arthropod-borne diseases reported in the last decades. Reports indicated that some vector-borne diseases such as Leishmaniasis and CCHF had the highest incidence rate and they need serious attention. However, some diseases reported from Iran are not endemic, and all cases were imported such as Dengue fever. A group of arthropod-borne diseases was reported only from animals, and the health of travelers is not threatened such as Eyeworm infection.

Surveillance for West Nile virus disease - United States, 2009-2018

PROBLEM/CONDITION

West Nile virus (WNV) is an arthropod-borne virus (arbovirus) in the family Flaviviridae and is the leading cause of domestically acquired arboviral disease in the contiguous United States. An estimated 70%-80% of WNV infections are asymptomatic. Symptomatic persons usually develop an acute systemic febrile illness. Less than 1% of infected persons develop neuroinvasive disease, which typically presents as encephalitis, meningitis, or acute flaccid paralysis.

REPORTING PERIOD

2009-2018.

DESCRIPTION OF SYSTEM

WNV disease is a nationally notifiable condition with standard surveillance case definitions. State health departments report WNV cases to CDC through ArboNET, an electronic passive surveillance system. Variables collected include patient age, sex, race, ethnicity, county and state of residence, date of illness onset, clinical syndrome, hospitalization, and death.

RESULTS

During 2009-2018, a total of 21 869 confirmed or probable cases of WNV disease, including 12 835 (59%) WNV neuroinvasive disease cases, were reported to CDC from all 50 states, the District of Columbia, and Puerto Rico. A total of 89% of all WNV patients had illness onset during July-September. Neuroinvasive disease incidence and case-fatalities increased with increasing age, with the highest incidence (1.22 cases per 100 000 population) occurring among persons aged ≥70 years. Among neuroinvasive cases, hospitalization rates were >85% in all age groups but were highest among patients aged ≥70 years (98%). The national incidence of WNV neuroinvasive disease peaked in 2012 (0.92 cases per 100 000 population). Although national incidence was relatively stable during 2013-2018 (average annual incidence: 0.44; range: 0.40-0.51), state level incidence varied from year to year. During 2009-2018, the highest average annual incidence of neuroinvasive disease occurred in North Dakota (3.16 cases per 100 000 population), South Dakota (3.06), Nebraska (1.95), and Mississippi (1.17), and the largest number of total cases occurred in California (2819), Texas (2043), Illinois (728), and Arizona (632). Six counties located within the four states with the highest case counts accounted for 23% of all neuroinvasive disease cases nationally.

INTERPRETATION

Despite the recent stability in annual national incidence of neuroinvasive disease, peaks in activity were reported in different years for different regions of the country. Variations in vectors, avian amplifying hosts, human activity, and environmental factors make it difficult to predict future WNV disease incidence and outbreak locations.

PUBLIC HEALTH ACTION

WNV disease surveillance is important for detecting and monitoring seasonal epidemics and for identifying persons at increased risk for severe disease. Surveillance data can be used to inform prevention and control activities. Health care providers should consider WNV infection in the differential diagnosis of aseptic meningitis and encephalitis, obtain appropriate specimens for testing, and promptly report cases to public health authorities. Public health education programs should focus prevention messaging on older persons because they are at increased risk for severe neurologic disease and death. In the absence of a human vaccine, WNV disease prevention depends on community-level mosquito control and household and personal protective measures. Understanding the geographic distribution of cases, particularly at the county level, appears to provide the best opportunity for directing finite resources toward effective prevention and control activities. Additional work to further develop and improve predictive models that can foreshadow areas most likely to be impacted in a given year by WNV outbreaks could allow for proactive targeting of interventions and ultimately lowering of WNV disease morbidity and mortality.

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.

Simultaneous circulation of two West Nile virus lineage 2 clades and Bagaza virus in the Zambezi region, Namibia

Flaviviruses include a great diversity of mosquito-borne arboviruses with epidemic potential and high global disease burden. Several flaviviruses are circulating in southern Africa affecting humans and livestock, among them West Nile virus (WNV) and Wesselsbron virus. Despite their high relevance, no arbovirus surveillance study has been conducted for more than 35 years in Namibia. In this study we assessed the diversity of flaviviruses circulating in mosquitoes in the densely populated, semi-tropical Zambezi region of north-eastern Namibia. In total, 10,206 mosquitoes were sampled in Bwabwata and Mudumu national parks and Mashi and Wuparo conservancies and screened for flavivirus infections. A high infection rate with insect-specific flaviviruses was found with 241 strains of two previously known and seven putative novel insect-specific flaviviruses. In addition, we identified ten strains of WNV in the main vector Cx. univittatus sampled in the Mashi conservancy. Surprisingly, the strains fell into two different clades of lineage 2, 2b and 2d. Further, three strains of Bagaza Virus (BAGV) were found in Cx. univittatus mosquitoes originating from Mudumu national park. Assessment of BAGV growth in different cell lines showed high replication rates in mosquito and duck cells and about 100,000fold lower replication in human, primate and rodent cells. We demonstrate a wide genetic diversity of flaviviruses is circulating in mosquitoes in the Zambezi region. Importantly, WNV and BAGV can cause outbreaks including severe disease and mortality in humans and birds, respectively. Future studies should focus on WNV and BAGV geographic distribution, as well as on their potential health impacts in and the associated social and economic implications for southern Africa.

Mosquitoes serve as vectors for the transmission of infectious diseases. Some of the most important mosquito-borne arboviruses belong to the genus Flavivirus, which can induce severe disease in humans and livestock. Surveillance of vector populations provide information on circulating arboviruses and may help to identify local outbreaks. Here we sampled mosquitoes over three wet seasons in the densely populated, semi-tropical Zambezi region of north-eastern Namibia and tested them for infections with flaviviruses. We observed simultaneous circulation of two different West Nile virus clades in the main vector species Cx. univittatus. Humans infected with West Nile virus can develop flu-like symptoms or in rare cases meningoencephalitis. Further, we detected Bagaza virus in Cx. univittatus from another locality and season. Bagaza virus infects birds leading to high mortality rates and may also infect humans. Our data suggest that both viruses are endemic in the Zambezi region and may affect human health and well-being in Namibia.

Surveillance for West Nile Virus Disease - United States, 2009-2018

Problem/Condition

West Nile virus (WNV) is an arthropodborne virus (arbovirus) in the family Flaviviridae and is the leading cause of domestically acquired arboviral disease in the contiguous United States. An estimated 70%–80% of WNV infections are asymptomatic. Symptomatic persons usually develop an acute systemic febrile illness. Less than 1% of infected persons develop neuroinvasive disease, which typically presents as encephalitis, meningitis, or acute flaccid paralysis.

Reporting Period

2009–2018.

Description of System

WNV disease is a nationally notifiable condition with standard surveillance case definitions. State health departments report WNV cases to CDC through ArboNET, an electronic passive surveillance system. Variables collected include patient age, sex, race, ethnicity, county and state of residence, date of illness onset, clinical syndrome, hospitalization, and death.

Results

During 2009–2018, a total of 21,869 confirmed or probable cases of WNV disease, including 12,835 (59%) WNV neuroinvasive disease cases, were reported to CDC from all 50 states, the District of Columbia, and Puerto Rico. A total of 89% of all WNV patients had illness onset during July–September. Neuroinvasive disease incidence and case-fatalities increased with increasing age, with the highest incidence (1.22 cases per 100,000 population) occurring among persons aged ≥70 years. Among neuroinvasive cases, hospitalization rates were >85% in all age groups but were highest among patients aged ≥70 years (98%). The national incidence of WNV neuroinvasive disease peaked in 2012 (0.92 cases per 100,000 population). Although national incidence was relatively stable during 2013–2018 (average annual incidence: 0.44; range: 0.40–0.51), state level incidence varied from year to year. During 2009–2018, the highest average annual incidence of neuroinvasive disease occurred in North Dakota (3.16 cases per 100,000 population), South Dakota (3.06), Nebraska (1.95), and Mississippi (1.17), and the largest number of total cases occurred in California (2,819), Texas (2,043), Illinois (728), and Arizona (632). Six counties located within the four states with the highest case counts accounted for 23% of all neuroinvasive disease cases nationally.

Interpretation

Despite the recent stability in annual national incidence of neuroinvasive disease, peaks in activity were reported in different years for different regions of the country. Variations in vectors, avian amplifying hosts, human activity, and environmental factors make it difficult to predict future WNV disease incidence and outbreak locations.

Public Health Action

WNV disease surveillance is important for detecting and monitoring seasonal epidemics and for identifying persons at increased risk for severe disease. Surveillance data can be used to inform prevention and control activities. Health care providers should consider WNV infection in the differential diagnosis of aseptic meningitis and encephalitis, obtain appropriate specimens for testing, and promptly report cases to public health authorities. Public health education programs should focus prevention messaging on older persons, because they are at increased risk for severe neurologic disease and death. In the absence of a human vaccine, WNV disease prevention depends on community-level mosquito control and household and personal protective measures. Understanding the geographic distribution of cases, particularly at the county level, appears to provide the best opportunity for directing finite resources toward effective prevention and control activities. Additional work to further develop and improve predictive models that can foreshadow areas most likely to be impacted in a given year by WNV outbreaks could allow for proactive targeting of interventions and ultimately lowering of WNV disease morbidity and mortality.

Co-circulation and misdiagnosis led to underestimation of the 2015-2017 Zika epidemic in the Americas

During the 2015-2017 Zika epidemic, dengue and chikungunya-two other viral diseases with the same vector as Zika-were also in circulation. Clinical presentation of these diseases can vary from person to person in terms of symptoms and severity, making it difficult to differentially diagnose them. Under these circumstances, it is possible that numerous cases of Zika could have been misdiagnosed as dengue or chikungunya, or vice versa. Given the importance of surveillance data for informing epidemiological analyses, our aim was to quantify the potential extent of misdiagnosis during this epidemic. Using basic principles of probability and empirical estimates of diagnostic sensitivity and specificity, we generated revised estimates of reported cases of Zika that accounted for the accuracy of diagnoses made on the basis of clinical presentation with or without laboratory confirmation. Applying this method to weekly reported case data from 43 countries throughout Latin America and the Caribbean, we estimated that 944,700 (95% CrI: 884,900-996,400) Zika cases occurred when assuming all confirmed cases were diagnosed using molecular methods versus 608,400 (95% CrI: 442,000-821,800) Zika cases that occurred when assuming all confirmed cases were diagnosed using serological methods. Our results imply that misdiagnosis was more common in countries with proportionally higher reported cases of dengue and chikungunya, such as Brazil. Given that Zika, dengue, and chikungunya appear likely to co-circulate in the Americas and elsewhere for years to come, our methodology has the potential to enhance the interpretation of passive surveillance data for these diseases going forward. Likewise, our methodology could also be used to help resolve transmission dynamics of other co-circulating diseases with similarities in symptomatology and potential for misdiagnosis.

Spatio-temporal impacts of aerial adulticide applications on populations of West Nile virus vector mosquitoes

BACKGROUND

Aerial applications of insecticides that target adult mosquitoes are widely used to reduce transmission of West Nile virus to humans during periods of epidemic risk. However, estimates of the reduction in abundance following these treatments typically focus on single events, rely on pre-defined, untreated control sites and can vary widely due to stochastic variation in population dynamics and trapping success unrelated to the treatment.

METHODS

To overcome these limitations, we developed generalized additive models fitted to mosquito surveillance data collected from CO2-baited traps in Sacramento and Yolo counties, California from 2006 to 2017. The models accounted for the expected spatial and temporal trends in the abundance of adult female Culex (Cx.) tarsalis and Cx. pipiens in the absence of aerial spraying. Estimates for the magnitude of deviation from baseline abundance following aerial spray events were obtained from the models.

RESULTS

At 1-week post-treatment with full spatial coverage of the trapping area by pyrethroid or pyrethrin products, Cx. pipiens abundance was reduced by a mean of 52.4% (95% confidence intrval [CI] - 65.6, - 36.5%) while the use of at least one organophosphate pesticide resulted in a mean reduction of 76.2% (95% CI - 82.8, - 67.9%). For Cx. tarsalis, at 1-week post-treatment with full coverage there was a reduction in abundance of 30.7% (95% CI - 54.5, 2.5%). Pesticide class was not a significant factor contributing to the reduction. In comparison, repetition of spraying over three to four consecutive weeks resulted in similar estimates for Cx. pipiens and estimates of somewhat smaller magnitude for Cx. tarsalis.

CONCLUSIONS

Aerial adulticides are effective for achieving a rapid short-term reduction of the abundance of the primary West Nile virus vectors, Cx. tarsalis and Cx. pipiens. A larger magnitude of reduction was estimated in Cx. pipiens, possibly due to the species' focal distribution. Effects of aerial sprays on Cx. tarsalis populations are likely modulated by the species' large dispersal ability, population sizes and vast productive larval habitat present in the study area. Our modeling approach provides a new way to estimate effects of public health pesticides on vector populations using routinely collected observational data and accounting for spatio-temporal trends and contextual factors like weather and habitat. This approach does not require pre-selected control sites and expands upon past studies that have focused on the effects of individual aerial treatment events.

Seroprevalence of West Nile Virus among Healthy Blood Donors from Different National Populations Residing in Qatar

OBJECTIVE

To estimate the age- and nationality-specific West Nile virus (WNV) seroprevalence in select Middle East and North Africa (MENA) populations residing in Qatar.

METHODS

Sera were collected from male blood donors attending Hamad Medical Corporation. A total of 1,948 sera were tested for anti-WNV antibodies using Serion ELISA classic IgG and IgM kits.

RESULTS

Overall, seroprevalence estimates of WNV-specific IgG and IgM antibodies were 10.4% and 3.3%, respectively. Country-specific WNV-specific IgG seroprevalence was estimated to be 37.0% (34/92) in Sudanese, 33.0% in Egyptians (66/200), 13.0% (26/200) in Indians, 10.6% (11/104) in Iranians, 10.2% (14/137) in Yemenis, 9.2% (18/195) in Pakistanis, 7.0% (14/199) in Jordanians, 5.4% (6/111) in Filipinos, 2.5% (5/200) in Palestinians, 2.5% (5/200) in Syrians, 1.5% (3/200) in Qataris, and 0.9% (1/110) in Lebanese. Seroprevalence of WNV-specific IgM was lowest in Iranians (0/77), Lebanese (0/108), and Filipinos (0/107) at 0.0%, and was highest in Sudanese at 10.0% (8/80). While there seemed to be apparent trends in the prevalence of WNV-IgM and WNV-IgG antibodies, none of these trends were found to be statistically significant.

CONCLUSION

The findings support the circulation of WNV in human populations in different countries of the MENA region. Seroprevalence was highest in Sudanese and Egyptians and lowest in Qataris and nationals of the Levant. The findings call for further animal, vector, and human studies, such as studying the actual prevalence of the viral RNA in blood donors to assess the risk of viral transmission through blood donation and for a better characterization of the epidemiology of this infection in this part of the world.

Clinical features and laboratory diagnosis of emerging arthropod-transmitted viruses: A Report from the Pan American Society for Clinical Virology Clinical Practice Committee

Arthropod-borne viruses (arboviruses) are an increasing global threat due to their ability to cause human disease and their expanding geographical distribution. They circulate in nature between arthropod vectors and vertebrate hosts. Infection of susceptible human hosts leads to harmful developmental and neurological manifestations. Arboviruses have caused recent outbreaks with significant public health implications, such as the Zika virus outbreak in the western hemisphere which caused fetal abnormalities in some infected pregnant women, or Eastern Equine Encephalitis which caused 15 deaths in 2019. This review discusses several arboviral infections and their clinical manifestations while highlighting the importance of laboratory diagnostics to detect infections and current attempts at vaccine development. The ability to accurately diagnose an arbovirus infection is critical for initiating a timely response to infections in order to improve patient outcomes.

Emergent Viral Infections of the CNS

Biological evolution of the microbiome continually drives the emergence of human viral pathogens, a subset of which attack the nervous system. The sheer number of pathogens that have appeared, along with their abundance in the environment, demand our attention. For the most part, our innate and adaptive immune systems have successfully protected us from infection; however, in the past 5 decades, through pathogen mutation and ecosystem disruption, a dozen viruses emerged to cause significant neurologic disease. Most of these pathogens have come from sylvatic reservoirs having made the energetically difficult, and fortuitously rare, jump into humans. But the human microbiome is also replete with agents already adapted to the host that need only minor mutations to create neurotropic/toxic agents. While each host/virus symbiosis is unique, this review examines virologic and immunologic principles that govern the pathogenesis of different viral CNS infections that were described in the past 50 years (Influenza, West Nile Virus, Zika, Rift Valley Fever Virus, Hendra/Nipah, Enterovirus-A71/-D68, Human parechovirus, HIV, and SARS-CoV). Knowledge of these pathogens provides us the opportunity to respond and mitigate infection while at the same time prepare for inevitable arrival of unknown agents.

The Role of Microglia during West Nile Virus Infection of the Central Nervous System

Encephalitis resulting from viral infections is a major cause of hospitalization and death worldwide. West Nile Virus (WNV) is a substantial health concern as it is one of the leading causes of viral encephalitis in the United States today. WNV infiltrates the central nervous system (CNS), where it directly infects neurons and induces neuronal cell death, in part, via activation of caspase 3-mediated apoptosis. WNV infection also induces neuroinflammation characterized by activation of innate immune cells, including microglia and astrocytes, production of inflammatory cytokines, breakdown of the blood-brain barrier, and infiltration of peripheral leukocytes. Microglia are the resident immune cells of the brain and monitor the CNS for signs of injury or pathogens. Following infection with WNV, microglia exhibit a change in morphology consistent with activation and are associated with increased expression of proinflammatory cytokines. Recent research has focused on deciphering the role of microglia during WNV encephalitis. Microglia play a protective role during infections by limiting viral growth and reducing mortality in mice. However, it also appears that activated microglia are triggered by T cells to mediate synaptic elimination at late times during infection, which may contribute to long-term neurological deficits following a neuroinvasive WNV infection. This review will discuss the important role of microglia in the pathogenesis of a neuroinvasive WNV infection. Knowledge of the precise role of microglia during a WNV infection may lead to a greater ability to treat and manage WNV encephalitis.

West Nile Virus: An Update on Pathobiology, Epidemiology, Diagnostics, Control and "One Health" Implications

West Nile virus (WNV) is an important zoonotic flavivirus responsible for mild fever to severe, lethal neuroinvasive disease in humans, horses, birds, and other wildlife species. Since its discovery, WNV has caused multiple human and animal disease outbreaks in all continents, except Antarctica. Infections are associated with economic losses, mainly due to the cost of treatment of infected patients, control programmes, and loss of animals and animal products. The pathogenesis of WNV has been extensively investigated in natural hosts as well as in several animal models, including rodents, lagomorphs, birds, and reptiles. However, most of the proposed pathogenesis hypotheses remain contentious, and much remains to be elucidated. At the same time, the unavailability of specific antiviral treatment or effective and safe vaccines contribute to the perpetuation of the disease and regular occurrence of outbreaks in both endemic and non-endemic areas. Moreover, globalisation and climate change are also important drivers of the emergence and re-emergence of the virus and disease. Here, we give an update of the pathobiology, epidemiology, diagnostics, control, and “One Health” implications of WNV infection and disease.

Culex erythrothorax (Diptera: Culicidae): Activity periods, insecticide susceptibility and control in California (USA)

The mosquito Culex erythrothorax Dyar is a West Nile virus (WNV) vector that breeds in wetlands with emergent vegetation. Urbanization and recreational activities near wetlands place humans, birds and mosquitoes in close proximity, increasing the risk of WNV transmission. Adult Cx. erythrothorax abundance peaked in a wetland bordering the San Francisco Bay of California (USA) during the first 3 hours after sunset (5527 ± 4070 mosquitoes / trap night) while peak adult Culex tarsalis Coquillett abundance occurred during the subsequent 3 h period (83 ± 30 Cx. tarsalis). When insecticide resistance was assessed using bottle bioassay, Cx. erythrothorax was highly sensitive to permethrin, naled, and etofenprox insecticides compared to a strain of Culex pipiens that is susceptible to insecticides (LC₅₀ = 0.35, 0.71, and 4.1 μg/bottle, respectively). The Cx. erythrothorax were 2.8-fold more resistant to resmethrin, however, the LC₅₀ value was low (0.68 μg/bottle). Piperonyl butoxide increased the toxicity of permethrin (0.5 μg/bottle) and reduced knock down time, but a higher permethrin concentration (2.0 μg/bottle) did not have similar effects. Bulk mixed-function oxidase, alpha-esterase, or beta-esterase activities in mosquito homogenates were higher in Cx. erythrothorax relative to the Cx. pipiens susceptible strain. There was no difference in the activity of glutathione S-transferase between the two mosquito species and insensitive acetylcholine esterase was not detected. Larvicides that were applied to the site had limited impact on reducing mosquito abundance. Subsequent removal of emergent vegetation in concert with larvicide applications and reduced daily environmental temperature substantially reduced mosquito abundance. To control Cx. erythrothorax in wetlands, land managers should consider vegetation removal so that larvicide can efficiently enter the water. Vector control agencies may more successfully control adult viremic Cx. erythrothorax that enter nearby neighborhoods by applying adulticides during the 3 h that follow sunset.

New onset of Bell's palsy in a patient with West Nile Encephalitis

The case report presented a patient who was diagnosed with West Nile virus encephalitis and developed new onset of Bell's palsy within 8 days of diagnosis. Given the incidence of WNV, it would be beneficial to evaluate WNV‐infected patients for peripheral neuropathy which nowadays has quite practical implication.