West Nile virus: epidemiology, clinical presentation, diagnosis, and prevention

Characterizing the West Nile Virus's polyprotein from nucleotide sequence to protein structure - Computational tools

Objectives

West Nile virus (WNV) belongs to the Flaviviridae family and causes West Nile fever. The mechanism of transmission involves the culex mosquito species. Infected individuals are primarily asymptomatic, and few exhibit common symptoms. Moreover, 10 % of neuronal infection caused by this virus cause death. The proteins encoded by these genes had been uncharacterized, although understanding their function and structure is important for formulating antiviral drugs.

Methods

Herein, we used in silico approaches, including various bioinformatic tools and databases, to analyse the proteins from the WNV polyprotein individually. The characterization included GC content, physicochemical properties, conserved domains, soluble and transmembrane regions, signal localization, protein disorder, and secondary structure features and their respective 3D protein structures.

Results

Among 11 proteins, eight had >50 % GC content, eight proteins had basic pI values, three proteins were unstable under in vitro conditions, four were thermostable according to >100 AI values and some had negative GRAVY values in physicochemical analyses. All protein-conserved domains were shared among Flaviviridae family members. Five proteins were soluble and lacked transmembrane regions. Two proteins had signals for localization in the host endoplasmic reticulum. Non-structural (NS) 2A showed low protein disorder. The secondary structural features and tertiary structure models provide a valuable biochemical resource for designing selective substrates and synthetic inhibitors.

Conclusions

WNV proteins NS2A, NS2B, PM, NS3 and NS5 can be used as drug targets for the pharmacological design of lead antiviral compounds.

West Nile Virus, an Underdiagnosed Cause of Acute Fever of Unknown Origin and Neurological Disease among Hospitalized Patients in South Africa

West Nile virus (WNV), a mosquito-borne flavivirus, is endemic to South Africa. However, its contribution to acute febrile and neurological disease in hospitalized patients in South Africa is unknown. This study examined two patient cohorts for WNV using molecular testing and IgM serology with confirmation of serological results by viral neutralization tests (VNT) to address this knowledge gap. Univariate analysis was performed using collected demographic and clinical information to identify risk factors. In the first cohort, 219 cerebrospinal fluid (CSF) specimens from patients with acute neurological disease in Gauteng hospitals collected in January to June 2017 were tested for WNV. The study identified WNV in 8/219 (3.65%, 95.00% CI (1.59-7.07)) patients with unsolved neurological infections. The second cohort, from 2019 to 2021, included 441 patients enrolled between January and June with acute febrile or neurological disease from urban and rural sites in Gauteng and Mpumalanga provinces. West Nile virus was diagnosed in 40/441 (9.07%, 95.00% CI (6.73-12.12)) of patients, of which 29/40 (72.50%, 95.00% CI (56.11-85.40)) had neurological signs, including headaches, encephalitis, meningitis, and acute flaccid paralysis (AFP). Notably, most of the cases were identified in children although adolescents and senior adults had a significantly higher risk of testing WNV positive. This suggests a previously underestimated disease burden and that WNV might be underrecognized as a cause of febrile and neurological diseases in hospitalized patients in South Africa, especially in children. This emphasizes the importance of further research and awareness regarding arboviruses of public health concern.

A Case of West Nile Encephalitis: Neuroimaging Findings and Clinico-Radiological Mismatch

West Nile Virus, an arthropod-borne RNA virus, may result in severe neurological disease. West Nile neuroinvasive disease is characterized by meningitis, encephalitis, and possible acute flaccid paralysis. Classically, signal intensity abnormalities on T2-weighted magnetic resonance images are associated with poor outcomes. Herein, we present a case of previous West Nile encephalitis with diffuse leukoencephalopathy on imaging that demonstrates a favorable clinical outcome with limited neurologic sequelae. A 53-year-old male presented to the hospital with one month of headaches, dizziness, generalized weakness, and a seizure. His initial neurologic exam was notable for wide-based gait and imbalance. Magnetic resonance imaging (MRI) of the brain demonstrated diffuse bilateral white matter signal hyperintensities without contrast enhancement, suggestive of leukoencephalopathy. His lumbar puncture revealed lymphocytic pleocytosis and infectious studies demonstrated positive West Nile Virus immunoglobulin G (IgG) in the cerebrospinal fluid (CSF) and serum with negative immunoglobulin M (IgM) in both CSF and serum, suggestive of previous infection. A diagnosis of sequelae of West Nile neuroinvasive disease was made. He was started on anti-seizure medications without further seizures. At his subsequent nine-month follow-up visit, he remained asymptomatic without weakness, headaches, or confusion. Repeat MRI demonstrated interval improvement of white matter signal change. This case report highlights that West Nile neuroinvasive disease may present with profound white matter changes on MRI with limited clinical symptoms and long-term neurologic sequelae. Further research is needed to identify imaging correlation with symptom severity in this disease.

Micro- and nanosystems for the detection of hemorrhagic fever viruses

Hemorrhagic fever viruses (HFVs) are virulent pathogens that can cause severe and often fatal illnesses in humans. Timely and accurate detection of HFVs is critical for effective disease management and prevention. In recent years, micro- and nano-technologies have emerged as promising approaches for the detection of HFVs. This paper provides an overview of the current state-of-the-art systems for micro- and nano-scale approaches to detect HFVs. It covers various aspects of these technologies, including the principles behind their sensing assays, as well as the different types of diagnostic strategies that have been developed. This paper also explores future possibilities of employing micro- and nano-systems for the development of HFV diagnostic tools that meet the practical demands of clinical settings.

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.

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.

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

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

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 of Four West Nile Virus Cases and Its Molecular Characterization from a South Indian Tertiary Care Hospital

West Nile virus (WNV) is currently a significant reemerging virus of the 21st century. It belongs to the family Flaviviridae and genus Flavivirus. Although it is primarily transmitted by the Culex spp of mosquitoes, other routes of transmission are also well defined. Of eight lineages described, Lineage 1a has been reported from many parts of South India and is known to cause neuroinvasive illness. Many tests and serological techniques have been described to diagnose WNV infection such as complement fixation, neutralization, heamagglutination inhibition, ELISA, and PCR for molecular confirmation. The latter far outweighs the limitations inherent in the other tests. WNV infection is being reported from Vellore for the first time after 1968. This paper aims to describe four cases of WNV infection causing central nervous system manifestations with its molecular characterization. West Nile virus infection was diagnosed with the available molecular techniques such as PCR and sequencing, which emphasizes the need for considering West Nile virus in the differential diagnosis of acute meningoencephalitis and the wider availability of molecular diagnostic tests.

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.

Predicting Chikungunya disease personal protective behaviors: Results of a cross-sectional survey of US-Caribbean travelers

Background: Incidents of vector-borne disease have recently tripled in the United States. Chikungunya disease is a particularly common disease in the Caribbean, posing a threat to international tourists. However, the relationship between psychological variables derived from the protection motivation theory (PMT), and adoption of protective behaviors against the disease, is uncertain. This study sought to identify the psychological predictors of travelers’ protective health behaviors, specifically (1) appropriate clothing use, and (2) indoor spatial repellent use.

Methods: An online, retrospective survey of U.S. international travelers to Caribbean destinations measured the five constructs of the PMT in the context of Chikungunya disease: Perceived severity, perceived vulnerability, perceived response efficacy, perceived self-efficacy, and knowledge. Hierarchical logistic regression analyzed whether these five theoretical constructs predicted the two protective behaviors in respondents who met study criteria (n = 184).

Results: Results suggest that the interaction between chikungunya knowledge and perceived chikungunya severity predicts both appropriate clothing use (odds ratio [OR]: 1.95, CI: 1.18-3.25, P =0.010) and indoor spatial repellent use (OR: 1.55, CI: 1.05-2.29, P =0.029). In the cases of appropriate clothing use, the interaction between perceived chikungunya severity and perceived vulnerability was also a significant predictor (OR: 9.67, CI:1.23-75.80, P =0.031). Additionally, indoor spatial repellent use was also predicted by the interaction of chikungunya knowledge and perceived vulnerability (OR: 1.88, CI:1.18-3.02, P =0.009).

Conclusion : Two-pronged educational approaches may be most efficacious in increasing protective health behaviors. Such efforts could reduce incidents of chikungunya disease and other vectorborne diseases in travel destinations featuring high exposure risks.

Predictive Modeling for West Nile Virus and Mosquito Surveillance in Lubbock, Texas

West Nile virus (WNV) was first detected in North America during 1999, and has since spread throughout the contiguous USA. West Nile virus causes West Nile fever and the more severe West Nile neuroinvasive disease. As part of a WNV vector surveillance program, we collected mosquitoes in Lubbock, Texas, using CO₂-baited encephalitic vector survey (EVS) traps. During 219 wk from 2009 through 2017, EVS traps were operated for 1,748 trap nights, resulting in more than 101,000 mosquitoes captured. Weekly, selected female mosquito specimens were pooled by species and trap site, and screened for WNV using reverse transcription-polymerase chain reaction assay. Mosquitoes positive for WNV were detected during 16.9% (37/219) of the weeks. Using this information, we constructed a statistical model to predict the probability of detecting an infection within a mosquito pool as a factor of weather variables. The final model indicated that detection of WNV in mosquitoes was negatively associated with the week of year squared and average wind from 3 wk prior to sampling, and was positively associated with week of year, average visibility, average humidity from 2 wk prior to sampling, and average dew point from 4 wk prior to sampling. The model developed in this study may aid public health and vector control programs in swift and effective decision making relative to city-wide mosquito control efforts by predicting when the chances of mosquitoes having WNV are at their greatest.

The Emerging Zika Virus Threat: A Guide for Dermatologists

We provide a guide for dermatologists to follow if they encounter patients with a rash and clinical history suspicious of Zika virus infection, including diagnostic testing and management options. We also provide an illustrative case report of a patient from Brazil who was diagnosed with Zika virus infection after presenting with a generalized pruritic rash. One of the most prominent symptoms of Zika virus infection is a cutaneous eruption. As such, it is especially necessary for dermatologists to understand this virus so that they may appropriately recognize this entity as a diagnostic consideration in the clinic. The rash associated with Zika virus infection is most commonly an erythematous maculopapular eruption that presents after an initial 3-4 days of fever, headache, and arthralgia or myalgia. The rash typically lasts for an average of 6 days, and can spread to involve any part of the body, including the face, torso, extremities, palms, and soles.

Review of West Nile virus circulation and outbreak risk in Madagascar: Entomological and ornithological perspectives

West Nile fever (WNF) is a zoonotic disease, occurring nearly globally. In Madagascar, West Nile virus (WNV) was first detected in 1978 from wild birds and the virus is currently distributed across the island, but no epidemic or epizootic period has been recorded. One fatal human case of WNV infection was reported in 2011, suggesting a "tip of the iceberg" phenomenon of a possible WNF epidemic/epizootic on the island. The main objective of this literature-based survey is to review patterns of WNV circulation in Madagascar from the entomological and ornithological points of view. Among the 235 mosquito species described from Madagascar, 29 species are widely associated with WNV infection; 16 of them are found naturally infected with WNV on the island and categorized into major, candidate, and potential vectors of WNV according to their vector capacity. This study upholds the hypothesis that WNV enzooticity is independent of annual movements of migratory birds passing through Madagascar. Moreover, the lack of regular migratory bird flux between Africa and Madagascar would reduce the probability of transmission and the subsequent reintroduction of the virus into locally occurring mosquito species. Given that Palearctic migratory birds are strongly implicated in the transmission of WNV, we highlight notable differences in the movements and species diversity of these birds in Madagascar as compared to eastern and northern Africa. Risk factors from this two-pronged approach are presented for the emergence of WNF outbreak.

Evaluation of the Control of West Nile Virus in Ontario: Did Risk Patterns Change from 2005 to 2012?

The goal of this study was to evaluate and compare the risk distribution of human cases of West Nile virus (WNV) disease in Ontario in 2005 to 2012. The objectives were to: map the risk distribution of WNV in 2005 and 2012, identify clusters of human WNV disease and determine whether the clusters are significantly different between the years 2005 and 2012. West Nile virus surveillance data were used to calculate empirical Bayesian smoothed estimates of disease incidence in southern Ontario for 2005 and 2012. Choropleth maps were generated to visualize the spatial risk distribution, and the spatial scan test was performed to identify clusters of disease. Following identification of clusters for 2005 and 2012, a Poisson model was applied to the 2012 human WNV incidence adjusted for the smoothed human WNV incidence rate from 2005 and the scan test was repeated. Two significant clusters were identified in both the year 2005 and 2012. In 2005, the primary cluster was located in the Windsor-Essex and Chatham-Kent public health units (PHUs). For 2012, the primary cluster was identified in the Golden Horseshoe area. A cluster analysis for 2012 adjusted for those identified in 2005 resulted in one significant cluster in the Windsor-Essex PHU. In 2012, the Windsor-Essex PHU remained as a high-risk area for human WNV disease when compared with the rest of southern Ontario. Although overall risk may change from year to year, public health programming should be employed to decrease the relative risk of WNV in this area.

West Nile Virus in Europe and Safety of Blood Transfusion

West Nile virus (WNV) has become an increasing issue in the transfusion setting since 2002, when it was firstly shown in the USA that it can be transmitted through blood transfusion. Since then, several precautionary measures have been introduced in Europe in order to reduce the possible risk of transmission via transfusion/solid organ transplantation. In addition, the epidemiological surveillance has been tightened and the network for communication of human WNV cases strengthened. This review will focus on WNV circulation and the safety of blood in Europe.

Detection and sequencing of West Nile virus RNA from human urine and serum samples during the 2014 seasonal period

West Nile virus, a widely distributed mosquito-borne flavivirus, is responsible for numerous animal and human infections in Europe, Africa and the Americas. In Hungary, the average number of human infections falls between 10 and 20 cases each year. The severity of clinically manifesting infections varies widely from the milder form of West Nile fever to West Nile neuroinvasive disease (WNND). In routine laboratory diagnosis of human West Nile virus infections, serological methods are mainly applied due to the limited duration of viremia. However, recent studies suggest that detection of West Nile virus RNA in urine samples may be useful as a molecular diagnostic test for these infections. The Hungarian National Reference Laboratory for Viral Zoonoses serologically confirmed eleven acute human infections during the 2014 seasonal period. In three patients with neurological symptoms, viral RNA was detected from both urine and serum specimens, albeit for a longer period and in higher copy numbers with urine. Phylogenetic analysis of the NS3 genomic region of three strains and the complete genome of one selected strain demonstrated that all three patients had lineage-2 West Nile virus infections. Our findings reaffirm the utility of viral RNA detection in urine as a molecular diagnostic procedure for diagnosis of West Nile virus infections.

Zika Virus in the Americas: A Review for Clinicians

Zika virus has recently emerged as a new public health threat. An arthropod-borne virus named after the Zika forest in Uganda, it was first discovered in 1947. The virus caused only sporadic cases of Zika infection in Africa and Southeast Asia until 2007, when the first large outbreak occurred in the Yap State in the Federated States of Micronesia. Another outbreak in French Polynesia in 2013 was notable for being associated temporally with an increase in cases of Guillain-Barré syndrome. In 2015, the virus was first reported in Brazil and since then has spread explosively through several additional countries in South and Central America and the Caribbean. Simultaneously, several of these countries have seen a dramatic increase in the incidence of infants born with microcephaly. The rapid spread of Zika virus through the Americas, together with the association of infection with microcephaly and Guillain-Barré syndrome, has resulted in the World Health Organization declaring a public health emergency. Zika virus has the potential to spread to new areas where the Aedes mosquito vector is present and therefore presents a risk to the United States. This concise review describes the clinical features of Zika virus infection and provides advice for clinicians on counseling travelers and others about the disease.

Seroprevalence screening for the West Nile virus in Malaysia's Orang Asli population

Background

West Nile virus (WNV) infection is an emerging zoonotic disease caused by an RNA virus of the genus Flavivirus. WNV is preserved in the environment through cyclic transmission, with mosquitoes, particularly Culex species, serving as a vector, birds as an amplifying host and humans and other mammals as dead-end hosts. To date, no studies have been carried out to determine the prevalence of the WNV antibody in Malaysia. The aim of this study was to screen for the seroprevalence of the WNV in Malaysia’s Orang Asli population.

Methods

Serum samples of 742 Orang Asli were collected in seven states in peninsular Malaysia. The samples were assessed to determine the seroprevalence of WNV immunoglobulin (Ig)G with the WNV IgG enzyme-linked immunosorbent assay (ELISA) method. For each individual, we documented the demographic factors. Anti-dengue and anti-tick-borne encephalitis virus IgG ELISA were also performed to rule out a cross reaction. All statistical analyses were performed using the GraphPad Prism 6 (GraphPad Software, Inc.); p values of less than 0.05 were considered significant.

Results

The serosurvey included 298 men (40.16%) and 444 women (59.84%) of Malaysia’s Orang Asli. Anti-WNV IgG was found in 9 of the 742 samples (1.21%). The seroprevalence was 0.67% (2 of 298) in men and 1.58% (7 of 444) in women. The presence of anti-WNV IgG was found not to be associated with gender but, however, did correlate with age. The peak seroprevalence was found to be 2.06% (2 of 97) in individuals between 30 to 42 years of age.

Conclusions

No previous studies have examined the seroprevalence of the WNV antibody in the human population in Malaysia, and no clinical reports of infections have been made. Screening for the WNV seroprevalence is very significant because of many risk factors contribute to the presence of WNV in Malaysia, such as the abundance of Culex mosquitoes as the main vector and a high degree of biodiversity, including migratory birds that serve as a reservoir to the virus.

Vaccination of mice using the West Nile virus E-protein in a DNA prime-protein boost strategy stimulates cell-mediated immunity and protects mice against a lethal challenge

West Nile virus (WNV) is a mosquito-borne flavivirus that is endemic in Africa, the Middle East, Europe and the United States. There is currently no antiviral treatment or human vaccine available to treat or prevent WNV infection. DNA plasmid-based vaccines represent a new approach for controlling infectious diseases. In rodents, DNA vaccines have been shown to induce B cell and cytotoxic T cell responses and protect against a wide range of infections. In this study, we formulated a plasmid DNA vector expressing the ectodomain of the E-protein of WNV into nanoparticles by using linear polyethyleneimine (lPEI) covalently bound to mannose and examined the potential of this vaccine to protect against lethal WNV infection in mice. Mice were immunized twice (prime – boost regime) with the WNV DNA vaccine formulated with lPEI-mannose using different administration routes (intramuscular, intradermal and topical). In parallel a heterologous boost with purified recombinant WNV envelope (E) protein was evaluated. While no significant E-protein specific humoral response was generated after DNA immunization, protein boosting of DNA-primed mice resulted in a marked increase in total neutralizing antibody titer. In addition, E-specific IL-4 T-cell immune responses were detected by ELISPOT after protein boost and CD8⁺ specific IFN-γ expression was observed by flow cytometry. Challenge experiments using the heterologous immunization regime revealed protective immunity to homologous and virulent WNV infection.

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.

West Nile virus neurologic disease in humans, South Africa, September 2008-may 2009

We investigated West Nile virus (WNV) as a possible disease etiology in persons hospitalized in South Africa. Of 206 specimens tested, 36 had WNV neutralizing antibodies, significantly more than in similar earlier serosurveys. Seven probable acute WNV cases were identified, suggesting WNV may be overlooked as an etiology of severe disease in South Africa.

Enhanced West Nile virus surveillance in a dengue-endemic area--Puerto Rico, 2007

In June of 2007, West Nile virus (WNV) was detected in sentinel chickens and blood donors in Puerto Rico, where dengue virus (DENV) is hyperendemic. Enhanced human surveillance for acute febrile illness (AFI) began in eastern Puerto Rico on July 1, 2007. Healthcare providers submitted specimens from AFI cases for WNV and DENV virology and serology testing. Over 6 months, 385 specimens were received from 282 cases; 115 (41%) specimens were DENV laboratory-positive, 86 (31%) specimens were laboratory-indeterminate, and 32 (11%) specimens were laboratory-negative for WNV and DENV. One WNV infection was detected by anti-WNV immunoglobulin M (IgM) antibody and confirmed by a plaque reduction neutralization test. DENV and WNV infections could not be differentiated in 27 cases (10%). During a period of active WNV transmission, enhanced human surveillance identified one case of symptomatic WNV infection. Improved diagnostic methods are needed to allow differentiation of WNV and DENV in dengue-endemic regions.

Phase II, dose ranging study of the safety and immunogenicity of single dose West Nile vaccine in healthy adults ≥ 50 years of age

INTRODUCTION

ChimeriVax-WN02 is a live, attenuated chimeric vaccine for protection against West Nile virus (WNV) produced by insertion of the genes encoding the pre-membrane (prM) and envelope (E) proteins of WNV (strain NY99) into the yellow fever 7D vaccine virus. This Phase II, randomized, double-blind, placebo-controlled, multi-center study in the US assessed the immunogenicity, viremia, and safety of the ChimeriVax-WN02 vaccine.

METHODS

The study included adults in general good health. Subjects aged ≥ 50 years were randomized to one of four treatment groups: ChimeriVax-WN02 4 × 10(3) plaque-forming units (pfu) (n=122), 4 × 10(4)pfu (n=124), 4 × 10(5)pfu (n=113), or placebo (n=120). A subset of subjects was randomized to assess viremia after vaccination at three different dose levels. Subjects were followed for safety up to 6 months after vaccination.

RESULTS

A total of 121 subjects for WN024 × 10(3), 122 for WN02 4 × 10(4), 110 for WN02 4 × 10(5), and 120 for the placebo group completed the study up to the 6-month safety follow-up. Seroconversion, as measured by plaque reduction neutralization test (PRNT), was achieved at Day 28 by 92.1%, 93.2%, and 95.4% of subjects in the WN02 4 × 10(3), the WN02 4 × 10(4), and the WN02 4 × 10(5) groups, respectively. Viremia was transient, detected between Days 2 and 14 but not at Day 28, and in most cases did not reach the quantification threshold. The percentage of subjects reporting at least one event of reactogenicity was similar in the placebo and active vaccine groups and showed no dose relationship.

CONCLUSIONS

The ChimeriVax-WN02 vaccine was highly immunogenic and well tolerated among subjects ≥ 50 years old at all dose levels.

Investigation of schizophrenic patients from Istanbul, Turkey for the presence of West Nile virus

Association of some neurotropic viruses like Borna Disease virus and Herpes virus with schizophrenia is better explained. However, the role of West Nile virus (WNV) infection in schizophrenia is not well documented. Therefore, this study was performed to investigate possible association between schizophrenia and presence of antibodies and WNV RNA in schizophrenic patients. For this, 200 blood samples from patients with schizophrenia and 200 from control groups were collected in Istanbul, Turkey. WNV RNA was not detected in any of the 200 patients and 200 controls analyzed by real-time RT-PCR. One hundred and twelve sera of schizophrenic patients and 162 of controls were analyzed for the presence of IgG antibodies to WNV by a commercial IgG-ELISA (Euroimmun, Germany). Antibodies to WNV were detected in 6 schizophrenic patients and 5 controls. ELISA positive patients had antipsychotic therapy. The difference between groups in terms of seropositivity to WNV was not statistically significant (p = 0.887, p = 0.148). Known symptoms of schizophrenia were observed in these patients, and interestingly majority had close contact to cats in the past and come from agricultural area of Turkey where potential area of mosquitoes and bird habitat. In conclusion, the results of this study show that antibodies to WNV in people do not seem to be associated with schizophrenia. However, detecting antibodies to WNV in schizophrenic patients suggests that WNV infection should be considered in endemic areas as it may play role in psychiatric diseases.

A West Nile virus DNA vaccine utilizing a modified promoter induces neutralizing antibody in younger and older healthy adults in a phase I clinical trial

BACKGROUND

West Nile virus (WNV) is a flavivirus that causes meningitis and encephalitis. There are no licensed vaccines to prevent WNV in humans. The safety and immunogenicity of a first-generation WNV DNA vaccine was demonstrated in a clinical trial and a similar DNA vaccine has been licensed for use in horses.

METHODS

A DNA vaccine encoding the protein premembrane and the E glycoproteins of the NY99 strain of WNV under the transcriptional control of the CMV/R promoter was evaluated in an open-label study in 30 healthy adults. Half of the subjects were age 18-50 years and half were age 51-65 years. Immune responses were assessed by enzyme-linked immunosorbent assay, neutralization assays, intracellular cytokine staining, and ELISpot.

RESULTS

The 3-dose vaccine regimen was safe and well tolerated. Vaccine-induced T cell and neutralizing antibody responses were detected in the majority of subjects. The antibody responses seen in the older age group were of similar frequency, magnitude, and duration as those seen in the younger cohort.

CONCLUSIONS

Neutralizing antibody responses to WNV were elicited by DNA vaccination in humans, including in older individuals, where responses to traditional vaccine approaches are often diminished. This DNA vaccine elicited T cell responses of greater magnitude when compared with an earlier-generation construct utilizing a CMV promoter.

CLINICAL TRIALS REGISTRATION

NCT00300417.

Phase II, randomized, double-blind, placebo-controlled, multicenter study to investigate the immunogenicity and safety of a West Nile virus vaccine in healthy adults

BACKGROUND

ChimeriVax-WN02 is a live, attenuated chimeric vaccine for protection against West Nile virus. This Phase II, randomized, double-blind, placebo-controlled, multicenter study assessed the immunogenicity, viremia, and safety of the ChimeriVax-WN02 vaccine.

METHODS

The 2-part study included adults in general good health. In part 1, subjects aged 18-40 years were randomized to 1 of 4 treatment groups: ChimeriVax-WN02 3.7- × -10(5) plaque-forming units (PFU), 3.7 × 10(4) PFU, 3.7 × 10(3) PFU, or placebo. In part 2, subjects aged 41-64 and ≥ 65 years were randomized to receive ChimeriVax-WN02 3.7 × 10(5) PFU or placebo.

RESULTS

In both part 1 and part 2, seroconversion was achieved at day 28 by >96% of subjects in active treatment groups. In part 1, neutralizing antibody titers at day 28 were higher and viremia levels lower with the highest dose, whereas the adverse event profile was similar between the dose groups. In part 2, antibody titers and viremia levels were higher in subjects aged ≥ 65 years, and more subjects in the 41-64 years cohort experienced adverse events.

CONCLUSIONS

The ChimeriVax-WN02 vaccine was highly immunogenic in younger adults and the elderly, and it was well tolerated at all dose levels and in all age groups investigated. Clinical Trials.gov identifier: NCT00442169.

Infectious disease in a warming world: how weather influenced West Nile virus in the United States (2001-2005)

BACKGROUND

The effects of weather on West Nile virus (WNV) mosquito populations in the United States have been widely reported, but few studies assess their overall impact on transmission to humans.

OBJECTIVES

We investigated meteorologic conditions associated with reported human WNV cases in the United States.

METHODS

We conducted a case-crossover study to assess 16,298 human WNV cases reported to the Centers for Disease Control and Prevention from 2001 to 2005. The primary outcome measures were the incidence rate ratio of disease occurrence associated with mean weekly maximum temperature, cumulative weekly temperature, mean weekly dew point temperature, cumulative weekly precipitation, and the presence of > or = 1 day of heavy rainfall (> or = 50 mm) during the month prior to symptom onset.

RESULTS

Increasing weekly maximum temperature and weekly cumulative temperature were similarly and significantly associated with a 35-83% higher incidence of reported WNV infection over the next month. An increase in mean weekly dew point temperature was significantly associated with a 9-38% higher incidence over the subsequent 3 weeks. The presence of at least 1 day of heavy rainfall within a week was associated with a 29-66% higher incidence during the same week and over the subsequent 2 weeks. A 20-mm increase in cumulative weekly precipitation was significantly associated with a 4-8% increase in incidence of reported WNV infection over the subsequent 2 weeks.

CONCLUSIONS

Warmer temperatures, elevated humidity, and heavy precipitation increased the rate of human WNV infection in the United States independent of season and each others' effects.

Frequency of missed cases of probable acute West Nile virus (WNV) infection when testing for WNV RNA alone or WNV immunoglobulin M alone

To estimate the frequency of missed cases of acute West Nile virus (WNV) infection if only WNV RNA or immunoglobulin M (IgM) testing is requested, we measured IgM in specimens negative for RNA and vice versa. Whereas 6 (5.5%) of 110 RNA-negative sera were IgM positive, only 3 (1.0%) of 299 IgM-negative sera were RNA positive (P < 0.05). Similarly, 11 (7.8%) of 141 RNA-negative cerebrospinal fluid specimens (CSF) were IgM positive, but 0 (0%) of 118 IgM-negative CSF were RNA positive (P < 0.05). WNV infections may be missed if only RNA or IgM testing is requested, with a higher frequency of missed cases if only RNA testing is requested.

A highly sensitive method for the detection and genotyping of West Nile virus by real-time PCR

In recent years, West Nile virus has been responsible for outbreaks in regions where it has not previously been found. Five genetic lineages with specific geographic distributions exist. Recent outbreaks of WNV associated with the introduction of lineage 1 strains into the western hemisphere, together with the emergence of lineage 2 WNV in Central Europe, has highlighted the potential for spread of pathogenic WNV strains beyond their expected geographical boundaries. Therefore, genotyping of WNV strains may have important applications in surveillance and epidemiology. We report here the development of a nested real-time PCR for the detection and genotyping of WNV strains by means of dissociation-curve analysis, using fluorescence resonance energy transfer (FRET) probe technology. Eight WNV strains, representing three lineages were tested and correctly genotyped at a detection limit of 0.07 viral genome copies/ml in one-step real-time RT-PCR or 7x10(-16) viral genome copies/ml in a nested real-time PCR. WNV could be identified and typed in serum and brain specimens from a human and horse with neurological disease. To our knowledge, this is the first assay designed for the simultaneous detection and genotyping of WNV by rapid, sensitive real-time PCR which may be implemented in diagnostic and epidemiology laboratories.

Predictive spatial models for risk of West Nile virus exposure in eastern and western Colorado

In the absence of a vaccine for use in humans against West Nile virus (WNV), mosquito control and personal protection against mosquito bites are the only measures available to prevent disease. Improved spatial targeting is desirable for costly mosquito and WNV surveillance and control schemes. We used a multivariate regression modeling approach to develop spatial models predicting high risk of exposure to WNV in western and eastern Colorado based on associations between Geographic Information System-derived environmental data and zip code of residence for 3,659 human WNV disease cases from 2002 to 2006. Models were robust, with user accuracies for correct classification of high risk areas of 67-80%. The importance of selecting a suitable model development area in an ecologically and climatically diverse environment was shown by models based on data from the eastern plains landscape performing poorly in the mountainous western part of Colorado and vice versa.

A West Nile virus DNA vaccine induces neutralizing antibody in healthy adults during a phase 1 clinical trial

BACKGROUND

West Nile virus (WNV) is a mosquito-borne flavivirus that can cause severe meningitis and encephalitis in infected individuals. We report the safety and immunogenicity of a WNV DNA vaccine in its first phase 1 human study.

METHODS

A single-plasmid DNA vaccine encoding the premembrane and the envelope glycoproteins of the NY99 strain of WNV was evaluated in an open-label study in 15 healthy adults. Twelve subjects completed the 3-dose vaccination schedule, and all subjects completed 32 weeks of evaluation for safety and immunogenicity. The development of a vaccine-induced immune response was assessed by enzyme-linked immunosorbant assay, neutralization assays, intracelluar cytokine staining, and enzyme-linked immunospot assay.

RESULTS

The vaccine was safe and well tolerated, with no significant adverse events. Vaccine-induced T cell and antibody responses were detected in the majority of subjects. Neutralizing antibody to WNV was detected in all subjects who completed the 3-dose vaccination schedule, at levels shown to be protective in studies of horses, an incidental natural host for WNV.

CONCLUSIONS

Further assessment of this DNA platform for human immunization against WNV is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00106769 .

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

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

Electroencephalographic characteristics of patients infected with west nile virus

SUMMARY

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

INTERPRETATION

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

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

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