zika, dengue, chikungunyazika, dengue, chikungunya after irma, maria and harvey pascal bittel...
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Zika, Dengue, Chikungunya after Irma, Maria and Harvey
Pascal Bittel Institute for Infectious Diseases Universität Bern 08.03.2018, Molecular Diagnostics Symposium Zurich
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Actors:
2
Pathogens Climate
Vectors Impact & Disease
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Dengue
3
A potentially lethal disease affecting >50 mio pp/y Lead Syptoms High Fever Mild rash
Mild muscle pain
Moderate joint pain
Moderate headache
Moderate bleeding
Shock (DHF)
DENV; ssRNA Flavivirus (Flaviviridae), 4 genotypes
Transmission via mosquitos
Exposure gives immunity to the same strain, but not others.
Secondary infection with different strain can lead to DHF
(2.5% of DHF are lethal)
Incubation period 3-7 days
Vaccine available (Dengvaxia)
Guzman, MG et al. The Lancet , Volume 385 , Issue 9966 , 453 - 465 Dengue
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Zika
4
Lead Symptoms Low/Moderate Fever
Strong rash Conjunctivitis Moderate joint pain
Mild muscle pain
Mild headache
The emerging arboviral pathogen of 2016
ZIKV; ssRNA Flavivirus (Flaviviridae)
WHO 2016 International Public Health Emergency
Transmission via mosquitos, sexual and intrauterine
Linked to birth defects (Microcephaly)
Linked to Guillain-Barré-Syndrome
Incubation period 3–12 days
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Chikungunya
5
Lead Symptoms High Fever Mild Rash
Mild conjuctivitis
Strong joint pain & swelling Mild muscle pain
Moderate headache
The painful third
CHIKV; ssRNA Alphavirus (Togaviridae)
Transmission via mosquitos
Some patients with persistent joint pains for months to
years
Incubation period 3–7 days
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Clinical Manifestation Summary
6
Symptom Dengue Chikungunya Zika (80% asymptomatic)
Fever ++++ ++++ ++
Headache +++ ++ +
Rash ++ ++ +++
Conjunctivitis + ++ ++
retro orbital pain ++ + +
muscle pain ++ + ++
joint pain/swelling + +++ ++
gastrointestinal symptoms + ++ +
Pruritus/dysaesthesia ++ + ++
Petechiae + - -
spontaneous bleeding + (+) -
Modified from Blum & Hatz, 2009; Neumayr & Hatz, 2016
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…but also other mosquito-borne viruses
7
West Nile Virus
Japanese Encephalitis Virus
La Crosse Virus
(Yellow Fever Virus)
St.Louis Encephalitis Virus
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Diagnostic Techniques
8
Serology Antigen Dengue rapidtests available (NS1Ag)
Molecular
IgM/G Crossreactions among flaviviruses
Only in acute phase (RT-PCR)
Cel. Virology Plaque Reduction Neutralization Test (Zika, Dengue; CDC)
https://www.swisstph.ch/en/travelclinic Information and recommendations of the Swiss Expert Committee of Travel Medicine (ECTM)
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Main Vectors
9 Kraemer, M. et al. Elife. 2015 Jun 30;4:e08347 The global distribution of the arbovirus vectors Aedes aegypti and Ae. albopictus
Ae. albopictus
Ae. aegypti
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Aedes Biology
10
● Adult life span: 14-21 days
● Female lays eggs 3-4 times in her life
● ca. 100-200 eggs per oviposition Egg → Larva: 2-3 days Larva → Pupa: 4-5 days Pupa → Adult: 1-2 days ● Blood meal required to develop eggs
● Vertical virus transmission possible
aquatic, container breeder
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Mosquitoborne-disease Season = Rainsaison
11 Wiwanitkit V. J Vector Borne Dis. 2006 Jun;43(2):73-6. An observation on correlation between rainfall and the prevalence of clinical cases of dengue in Thailand
Den
gue
inci
denc
e
Average rainfall
98%
3.5%
5.-13.2.2016
5.-21.8.2016
Risk to be stung by an Aedes mosquito
Chr
isto
ph H
atz,
TPH
, 201
6
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Worldwide tropical storm paths
12 NASA Earth Observatory
«Dengue-belt» Tracks and intensities of tropical storms 1951-2007
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Climate
13
HARVEY 215km/h 17.8.17-3.9.17
US National Hurricane Center; https://www.nhc.noaa.gov
IRMA 298km/h 30.8.17-14.9.17
MARIA 282km/h 16.9.17-30.9.17
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Climate
Atlantic Hurricane Season: June – November ↑Sept Pacific Hurricane Season: May – September ↑Sept Pacific Typhoon Season: June – October ↑Aug Australian / Southern Cyclone Season: November – April ↑Feb
14
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Impact and Aftermath
15 Zorilla CD, N Engl J Med 2017; 377:1801-1803 The View from Puerto Rico — Hurricane Maria and Its Aftermath
San Juan, Puerto Rico; Maria
“As of 16 days after the hurricane, 25 of 69 hospitals were working, only 9.2% of people had power, 54% had water, 45% had cell phone service”
St. Maarten; Irma
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Arboviral diseases are not a 1. line priority
16
► Flood water contaminated by fecal material: Typhoid fever and cholera
► Safety concerns including potential crime and violence
► Caring for those directly injured during the storm
► Inadequate food and water supplies
► Rebuilding of a basic functional infrastructure
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The question
17
Hurricane events increase the incidence of cases of mosquito-arboviral diseases. or Hurricane events have little or no effect on the incidence of cases of mosquito-arboviral diseases.
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Facts pro
18
Hurricane events increase incidence of cases • Increased rainfall and flooding • Accumulation of water puddles: New breeding grounds for mosquitoes Mosquito populations may increase • Suspended vector control measures • Displacement of large numbers of people into crowded shelters / camps (3. world, global south)
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Facts contra
19
Hurricane events have little or no effect on the incidence of cases • Strong winds, salt water surge, downpours: Displace or kill mosquitoes, «flush-out effects» Adult Mosquitos don’t survive hurricane level storms • Altered ecology past event: Disruption of vertical transmission: New freshly hatched mosquitoes are virus-free Weeks for recovery of virus in population • Mass-evacuation of people to less affected (e.g. dry) inland-areas: Reduction of active reservoires (1. world)
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Post-Hurricane arboviral outbreaks?
20
Available data say NO, (but…)
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Post-Hurricane arboviral outbreaks?
21
Available data say NO, (but…) Joe Posid, CDC
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22
● 11 cases within 3 weeks past-event ● only 1 out of 150 WNF-patients develops neuroinvasive disease
Post-Hurricane arboviral outbreaks?
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The CDC's and ECDC’s opinion
23 https://www.cdc.gov/zika/vector/mosquitoes-and-hurricanes.html
“Although flooding caused by hurricanes can be severe and an increase in mosquito populations is expected in the coming weeks, CDC does not generally expect to see a substantial increase in the incidence of mosquito-borne diseases.”
But why is the topic so much discussed then?
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Public awareness vs. empirical evidence
24
Hurricane events increase incidence of cases
Hurricane events have little or no effect on incidence of cases, but…
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If, then late…
Mosquito-borne diseases are hurricane late-consequences: ● Mosquito population has to rebuild: weeks (most adults are dead) ● Virus has to reestablish in the mosquito population
25
Affected areas have time to react (but also lots of other problems)
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A complex network…
► Data must be integrated into multidisciplinary studies of pathogen dynamics and transmission risk
Mar
ian
Kam
ensk
y
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Main Influencing Factors: Uncontrollable
27
Early in rainseason = risk of transmission may rise
Late in rainseason = risk may even decrease
Time and location of the hurricane event is important:
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Main Influencing Factors: Uncontrollable
28
Early in rainseason = risk of transmission may rise
Late in rainseason = risk may even decrease
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Manmade Influencing Factors
29
Basic needs have to be fullfilled before affected areas can «switch back from disaster survival mentality» Mosquito control is not a 1st priority action after a major hurricane event.
Governmental/Social efficiency for disaster control
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Vector Surveillance / Mosquito control
30
Recommendations of WHO Vector Control Advisory Group (VCAG)
http://www.who.int/neglected_diseases/news/mosquito_vector_control_response/en
● Vector traps ● Targeted residual spraying ● Space spraying ● Larval control (source reduction / larviciding) ● Personal protection measures (repellents)
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Advanced Mosquito control techniques
● Microbial control of human pathogens in adult vectors using Wolbachia and Incompatible insect technique (IIT)
Terradas G, McGraw EA.; Curr Opin Insect Sci. 2017 Aug;22:37-44. Wolbachia-mediated virus blocking in the mosquito vector Aedes aegypti
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Advanced Mosquito control techniques
Ritchie SA et al.; Trends Parasitol. 2018 Mar;34(3):217-226 Mission Accomplished? We Need a Guide to the 'Post Release' World of Wolbachia for Aedes-borne Disease Control
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Advanced Mosquito control techniques
● Microbial control of human pathogens in adult vectors using Wolbachia and Incompatible insect technique (IIT) ● Sterile insect technique (SIT), Ae. aegypti OX513A
Terradas G, McGraw EA.; Curr Opin Insect Sci. 2017 Aug;22:37-44. Wolbachia-mediated virus blocking in the mosquito vector Aedes aegypti
Ritchie SA, Johnson BJ.; J Infect Dis. 2017 Mar 1;215 Advances in Vector Control Science: Rear-and-Release Strategies Show Promise
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34
Advanced Mosquito control techniques
● Microbial control of human pathogens in adult vectors using Wolbachia and Incompatible insect technique (IIT) ● Sterile insect technique (SIT), Ae. aegypti OX513A Hurricane events as chances?
Terradas G, McGraw EA.; Curr Opin Insect Sci. 2017 Aug;22:37-44. Wolbachia-mediated virus blocking in the mosquito vector Aedes aegypti
Ritchie SA, Johnson BJ.; J Infect Dis. 2017 Mar 1;215 Advances in Vector Control Science: Rear-and-Release Strategies Show Promise
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Disease Surveillance
35
CDC Arbonet: US national arboviral surveillance system Operational since 2000. Passive surveillance system. Clinicians/scientists obtaining the appropriate diagnostic tests, reporting the diagnosis of arboviral diseases, laboratory-analysis and vector surveillance data. Can be combined with climate data. Actively curated and can be used as a modelling instrument.
National surveillance and detection systems In non-industrialized countries often incomplete or non-existent. Little predictive value.
Multidisciplinary Surveillance
https://wwwn.cdc.gov/arbonet/
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Virus surveillance?
36
Isothermal amplification methods? A tool for field virus surveillance..?
Low-tech molecular diagnostics:
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Summary
37
● Hurricane events can create new mosquito breeding sites.
● Recovery of mosquito population typically takes some weeks.
● Adult mosquitos generally do not survive hurricane level storms.
● The dangers of post-hurricane arboviral outbreaks are often exaggerated in mass media.
● No major post-hurricane arboviral outbreaks have been reported However, if conditions are right, post-hurricane arboviral outbreaks can’t be excluded
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Arboviral outbreak after hurricane-event?
38
time of year
location
disaster response
situation before event
Outbreak
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Thank you for you attention
Questions?
39