The Movement of West Nile Virus in North America

UC Berkeley October 1, 2003

Photo of Cx. quinquefasciatus courtesy of Dr. Stephen Higgs, UTMB/Galveston

Lyle R. Petersen, M.D., M.P.H.. Division of Vector-Borne Infectious Diseases Fort Collins, Colorado

Order of Topics
What is it? What is different now? How did it get here? How it is spreading? How big is the problem? What will happen next? How do we prevent it?

West Nile Virus: Background

RNA virus Family Flaviviridae, Genus Flavivirus Member Japanese encephalitis serocomplex Closely related to SLE virus Isolation in 1937, West Nile district of Uganda

West Nile Virus: Approximate Geographic Range Before 1999

West Nile Virus Before and After Mid-1990s

Before Mild self-limited febrile illness Central nervous system involvement rare Periodic outbreaks After Outbreaks associated with severe CNS illness Some outbreaks associated with avian mortality First recognition in North America (New York City) in 1999

West Nile Outbreaks

Israel 1941, 1951-1954, 1957, 1980, 2000 France 1962, 2000 South Africa 1974 Romania 1996 Italy 1998 Russia 1999 United States 1999-2003

Arrival in North America

Phylogenetic Tree of West Nile Viruses

Clade
Egypt 1951 France 1962 South Africa 1974 Eg 101

LINEAGE

NE United States U.S./Israel Israel 98/99/2000 Romania 1996 Europe/Russia Italy 1998 Volgograd 1999 Israel 2000 India Kunjin Madagascar Uganda 1937 Central African Republic India Kunjin

An exotic arbovirus in NYC was surprising and unexpected: Should it have been?

International Animal Importations Into New York August 1998 July 1999 N = 2,873,144

Animals

none 1 6000 6001 - 20000 20001 - 50000 50001 - 350000 350001 -

Top Ten Countries of Origin Passengers arriving into NY Airports July 1998 June 1999 N = 4,850,090
Country DOMINICAN REPUBLIC UNITED KINGDOM CANADA FRANCE MEXICO ITALY JAPAN BRAZIL ISRAEL BAHAMAS GERMANY BERMUDA Passengers Percent 539,740 11% 456,540 9% 350,510 7% 312,400 6% 310,330 6% 215,040 4% 177,810 4% 157,220 3% 153,540 3% 143,390 3% 129,690 3% 114,750 2%

West Nile Virus Transmission Cycle

Mosquito vector
Incidental infections

West Nile Virus

West Nile Virus

Incidental infections

Bird reservoir hosts

West Nile Virus Amplification Cycle

Enzootic/epizootic (amplifying) vectors
Culex pipiens Cx. restuans Cx. quinquefasciatus Cx. tarsalis

Incidental hosts
Humans Horses Other mammals

Other mosquito vectors*

Culex salinarius Cx.nigripalpus Ochlerotatus sollicitans Oc. taeniorhynchus Aedes vexans Ae albopictus

Amplifying hosts
Passerine birds

?
* With possible epidemic potential

West Nile Virus Ecology in North America, as of Fall 2003

43 mosquito species 170 native and captive avian species Mortality varies greatly by species Very high viremias in some species Bird-to-bird transmission documented Virus in feces and oral swabs Oral infection possible 18 other species (e.g., cats, dogs, squirrels, chipmunks, harbor seal, alligator, bats, reindeer)

WNV Surveillance
Dead birds (especially crows) Human surveillance Mosquitoes Horse surveillance Live captive sentinels (e.g. chickens) Live wild birds Zoo animals

States and Counties Reporting WNV Activity, United States, 1999-2003*

Year
1999 2000

# States
4 12**

# Counties
28 145

Date Range
9 AUG 15 NOV 6 FEB 17 NOV

2001
2002 2003

27**
44** 45

359
2,531 1,954

8 APR 26 DEC
3 JAN 19 DEC 1 JAN 29-SEP

Reported to ArboNET as of 09/03/2003

** Plus D.C.

Reported WNV Disease Cases in Humans, United States, 1999-2003*

Year # Cases # States # Counties Onset Date Range

1999
2000 2001 2002 2003

62
21 66 4,156 5,722

1
3 10 39** 41

6
10 39 740 730

2 AUG 24 SEP
20 JUL 27 SEP 13 JUL 7 DEC 19 MAY 19 DEC 28 MAR 26 SEP

* Reported as of 09/30/2003

** Plus D.C.

Clinical Epidemiology
Incubation period 2-14 days May be longer in immunosuppressed Approximately 20% mild febrile illness <1% severe neurological disease Meningitis, encephalitis, AFP Advanced age primary risk factor for encephalitis AFP patients may be younger Immunosuppressive drugs and hematological malignancies risk factors Approximate 10% mortality Long-term morbidity common

WNV Human Infection Iceberg in 2002

284 fatalities ~ 3300 severe disease ~100,000 mild illness
<1% CNS disease ~20% West Nile Fever

~400,000 asymptomatic

~80% Asymptomatic

Human WNV Illnesses (n=4156), by Month of Symptom Onset, 2002

2200 2000 1800 1600 1400 1200 1000 800 600 400 200 0
l b Ma rch Ja n Ap ri Fe

1st Case May 19

Last Case Dec 19

# cases

Ma y

ly

Au g

Month of Onset

Ju

Se p

Ju

No v

De c

Oc t

ne

Human WNV Meningoencephalitis Incidence, by Age Group, United States, 2002

60

Incidence per Million*

50 40 30 20 10 0

0-9

-1 9 0 1

-29 0 2

-39 0 3

-49 0 4

-59 0 5

-69 0 6

-79 0 7

-89 0 8

-9 9 0 9

Age group (yr)

* States with human cases

Fatality Rate among Persons with WNV Meningoencephalitis, by Age Group, United States, 2002
40

Fatality Rate (percent)

35 30 25 20 15 10 5 0

0-9

-1 9 0 1

-29 0 2

-39 0 3

-49 0 4

-59 0 5

-69 0 6

-79 0 7

-89 0 8

-9 9 0 9

Age group (yr)

Human WNV Disease Cases, by Age Group and Clinical Category, United States, 2003*
Proportion of disease cases (%)
30

WNME

WNF

20

10

0
0-9 -19 0 1 -2 9 0 2 -3 9 0 3 -49 0 4 -59 0 5 -69 0 6 -79 0 7 -89 0 8 -99 0 9

Age group (yr)

* Reported as of 09/03/2003

Novel Modes of West Nile Virus Transmission, 2002

Transplanted organs One donor to four recipients Transfused blood 23 confirmed cases in 2002, many more likely WNV screening began in July Breast milk One case, infant asymptomatic Transplacental transmission One case, severe outcome to infant Percutaneous, occupational exposure

St. Louis Encephalitis

Related Japanese encephalitis serocomplex flavivirus Endemic in the Americas Similar maintenance vectors Birds are main hosts Causes human epidemics Is SLE a model for the future behavior of WNV?

2500

Reported and Estimated Number of St. Louis Encephalitis Cases, U.S., 1932- Sept 12, 2003

2000

1500

1000

500

0 1932

1942

1952

1962

1972

1982

1992

2002

Reported Number of West Nile Meningoencephalitis Cases, U.S., 1932- Sep 30, 2003
2500

2000

1500

1000

500

0 1932

1942

1952

1962

1972

1982

1992

2002

SLE 1975

DC

Reported Incidence in Humans: SLE 1975 vs. WNME 2002 WNME 2002*

Incidence per 106 >=10

1 9.9
0 0.9

DC

* Reported as of 11/01/2002

West Nile Virus Future in the United States

Worrisome for several reasons Prolonged transmission season Wide geographic range Many potential amplifying avian hosts High viremias in birds Many potential mosquito vectors Many potential human-biting mosquito species Persistent infections in areas over 5 years Urban / suburban / rural transmission

JOIN THE SWAT TEAM AGAINST WEST NILE VIRUS

Prevention
Repellants DEET (up to 50% concentration); 10% in children Permethrin on clothing and fabrics Reduce mosquito breeding sites Long sleeves and pants Stay indoors when mosquitoes are biting (dawn and dusk) Bug zappers, sonic devices, CO2 devices (mosquito magnet): no proven efficacy

Habitat elimination

Larviciding

Adulticiding