ViralEncephalitis

Viral Encephalitis : Viral Encephalitis


Viral Encephalitis : Viral Encephalitis Western equine encephalitis (WEE) Eastern equine encephalitis (EEE) St. Louis encephalitis (SLE) La Crosse encephalitis (LAC) Venezuelan equine encephalitis (VEE) West Nile virus (WNV)


History : History


History : History 1925 First arbovirus identified in the U.S. Vesicular stomatitis Indiana virus 1930 WEE virus isolated in California Karl Meyer isolated agent from horse brain Coincided with human polioencephalomyelitis cases


History : History 1932 Aedes aegypti replicate and transmit WEE in the laboratory St. Louis encephalitis identified in causing human disease 1933 St. Louis encephalitis virus isolated from human brain Eastern equine encephalitis virus Isolated from equine brains Along eastern seaboard of the U.S.


History : History 1938 WEE and EEE isolated from human brain tissue 1941 Culex tarsalis mosquitoes found to be naturally infected with WEE


Transmission : Transmission


Transmission : Transmission Virus Particles Dead End Hosts Vertebrate Hosts Mosquito Vector Transovarial & Venereal


Mosquito Life Cycle : 4 stages Egg, larva, pupa, adult Aedes species Lay single eggs Damp soil, later flooded Culex species 100-300 eggs in raft Lay eggs at night on water surface Survival requires wind protection Overwinter in egg stage Mosquito Life Cycle


Mosquito Life Cycle : Mosquito Life Cycle Larvae live upside down in water; “wriggler” Breathe via siphon tube Molt 4 times Pupal stage is restful, non-feeding; “tumbler” Breathe via “trumpets” Splits to allow adult to emerge Larva Pupa


Mosquito Life Cycle : Newly emerged adult rests Dry off wings in order to fly Harden body parts Takes blood meal Mates a few days after flight Attractants for biting Carbon dioxide, temperature, moisture, smell, color, movement Lifespan varies from 4-30 days Mosquito Life Cycle


Arboviruses Indigenous to the United States : Arboviruses Indigenous to the United States


Human Clinical Signs : Human Clinical Signs Most cases are asymptomatic Flu-like illness in some Sudden fever, headache, myalgia, malaise, prostration Small proportion develop encephalitis Permanent neurological damage Death


Human Treatment : Human Treatment Manage symptoms Reduce fever Maintain hydration and electrolytes Maintain blood oxygen levels Anticonvulsants Osmotic diuretics for intracranial pressure Physical therapy No effective anti-virals available


Summary of Encephalitis Viruses Within the U.S. : Summary of Encephalitis Viruses Within the U.S.


Arboviruses Indigenous to the United States : Arboviruses Indigenous to the United States


Human Risks and Outcomes : Human Risks and Outcomes St. Louis Encephalitis (SLE) Most common Elderly most at risk Case fatality rate: 5-15% La Crosse Encephalitis (LAC) Children <16 years most at risk Human fatalities less than 1% Average 73 cases/year 4478 confirmed cases


Human Risks and Outcomes : Human Risks and Outcomes Eastern Equine Encephalitis (EEE) Elderly most at risk Case fatality rate: 33% WEE Children younger than 1 year most at risk Case fatality rate approximately 3% VEE Children most often affected Fatalities are rare Average 5 cases/year Average 19 cases/year; < 1/year last 10 years


Animal Risks and Outcomes : Animal Risks and Outcomes Horse - Case-fatality rate EEE ~ 90% VEE ~ 40-80% WEE ~ 20-50% Vaccine available in the U.S. Trivalent formalin-inactivated SLE, LAC do not cause disease in horses or other non-human mammals


California Serogroup(CAL) : California Serogroup (CAL) La Crosse virus Jamestown Canyon virus Cache Valley Others


California Serogroup : California Serogroup First isolated in 1943 Approximately 14 known viruses 10 known to cause human disease La Crosse virus Only member known to cause human mortality Ochleratatus (Aedes) triseriatus (treehole mosquito) vector No two field isolates the same Genetic change constantly occurring


Slide23 : CAL in the U.S.: 1993-2002 50 40 30 20 10 0 Reported Cases 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Year (Month) MMWR Encephalitis/Meningitis, California Serogroup Viral. Reported cases in U.S., 1993-2002


CAL Epidemiology : CAL Epidemiology Primarily in Western Hemisphere Can occur in Africa, Asia, Europe Virus transmission and amplification Occurs in wild vertebrate hosts Rodents, chipmunks, deer, reindeer Domestic animals are sentinels Mosquitoes are largest reservoir Ochleratatus (Aedes) species


La Crosse Encephalitis: History : La Crosse Encephalitis: History 1963 Discovered in La Crosse, WI Causes human mortality 4-year-old girl died of acute encephalitis Cases since reported in other Midwestern and Mid-Atlantic states Bunyavirus Ochleratatus (Aedes) triseriatus


LAC Transmission : transovarial Ochleratatus (Aedes) triseriatus Virus present in new adult Vertebrate host Dead end host LAC Transmission Newly infected transmits to vertebrate host


LAC Epidemiology : LAC Epidemiology Human cases 75 cases reported each year In 27 states Greatest risk for clinical disease Children less than 16 years old Cases often un- or misdiagnosed Case-fatality rate: < 1%


Slide28 : Average 73 cases/year


La Crosse in Humans : La Crosse in Humans Incubation: 2-7 days Summertime illness Fever, headache, nausea, vomiting, lethargy More severe disease in children <16 Seizures, coma, paralysis, neurological sequelae Death less than 1% of cases Not often correctly diagnosed


La Crosse in Humans : La Crosse in Humans Diagnosis Hemagglutination inhibition Paired sera monitoring for rise in antibody titer Treatment Supportive Manage seizures and increased intracranial pressure Prognosis poor with severe clinical disease No vaccine available


Animals and LAC : Animals and LAC Incubation period: 24-48 hours Short-lived viremia Many wildlife species seroconvert Asymptomatic No known protocols for treatment, prevention or control


Eastern Equine Encephalitis : Eastern Equine Encephalitis


EEE History : EEE History 1831 Massachusetts horses afflicted with unknown encephalitis virus 1933 First isolated from a horse 1942-1943 Michigan epidemic Most epidemics along eastern seaboard and gulf states


EEE History : EEE History 1947: Southern LA and TX 14,000 horses, mules affected 83% fatality 1951 Isolated from Culiseta melanura mosquito Last 25 years Most horse cases in Florida 1982 and 1983: over 500 cases 1991: 159 cases


EEE History : EEE History Human cases not as prevalent 1964-2002: 182 cases 1937 Disease identified in ring-necked pheasants Also occurs in sparrows, pigeons, partridges, emus and ostriches


EEE Transmission : Culiseta melanura Pecking transmission Aedes spp. Coquilletidia perturbans Dead end hosts: Horses, humans, other mammals Bird migration Over wintering? Spring Reintroduction Summer Swampy areas EEE Transmission


EEE Epidemiology : EEE Epidemiology 1964-2002 182 cases total since 1964 Average 6 cases each year Average 1-2 deaths each year Case-fatality rates Human: 30-70% Equine: 90% Horse cases appear before human cases Serve as sentinels


Slide38 : 5 cases per year


Slide39 : EEE in the U.S.: 1993-2002 Year (Month) 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Reported Cases 6 5 4 3 2 1 0 MMWR Encephalitis/Meningitis, Eastern Equine. Reported cases in U.S., 1993-2002


Human EEE : Human EEE Incubation period: 4-10 days Milder disease less common Fever, myalgia, headache, nausea, vomiting, abdominal pain and photophobia Seizure and coma in severe cases Longer fever and flu-like symptoms before CNS signs results in a better outcome


Human EEE : Human EEE Survival rates associated with age Highest in young adults-70% Lower in children-60% Lowest in elderly-30% Recovery can result in permanent brain damage Diagnosis by serology Treatment is supportive care


Animal EEE : Animal EEE Incubation period: 1-8 days Severe disease Horses, pheasants, quail, ostriches, emus, puppies Clinical signs in horses Fever, anorexia, weight loss, depression CNS signs Wide stance, droopy ears, flaccid lips, hanging head Death in horses within 4 days


Animal EEE : Animal EEE Diagnosis with ELISA Detects serum IgM titers Vaccine does not elicit IgM response Provide surveillance for human cases Treatment difficult Poor prognosis Vaccination available Two inoculations 1 month apart Booster every six months


Animal EEE : Animal EEE Clinical signs in birds Depression, tremors, leg paralysis, somnolence Emus, ostriches Hemorrhagic enteritis, emesis Death 24 hours after onset Vaccination Emus & ostriches with equine vaccine Whooping cranes with experimental human vaccine


Western Equine Encephalitis : Western Equine Encephalitis Forage poisoning, Cerebrospinal meningitis, Corn-stalk disease, Harvest disease, Sleeping sickness


WEE History : WEE History 1930 Isolated from horse brain 6,000 horses affected in California 50% case fatality rate 1933 Aedes aegypti mosquitoes experimentally infected with WEE Transmit virus to guinea pigs 1936, transmit virus to horses 1938 Isolated from human brain


WEE History : WEE History 1941 Culex tarsalis mosquito found naturally infected in Washington 1941 Major epidemic in Canada and north central United States High fatality rates 1942 Culex tarsalis is the vector 1943 Identified as mosquito-borne, using birds as reservoir host


WEE Transmission : WEE Transmission Dead-end hosts: Horses, humans Culex tarsalis Primary Vector Primary Vertebrate Hosts House Sparrow House Finch P. Myers Secondary Amplifiers Blacktail Jackrabbit Prairie Dog B. Lundrigan P. Myers


WEE Transmission : WEE Transmission


WEE Epidemiology : WEE Epidemiology Culex tarsalis Reaches high populations in mid to late summer Epidemics associated with cool, wet spring Wind can carry mosquitoes 800 miles in less than 24 hours Cases appear in June-August 639 cases since 1964 1989-1997: No human deaths


Slide51 : Average 19 cases/year; <1/year last 10 years


Slide52 : WEE in the U.S.: 1993-2002 MMWR 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2 1 0 Reported Cases Year


Human WEE : Human WEE Incubation: 5-10 days Sudden onset of fever, headache, nausea, vomiting, anorexia, malaise CNS signs in children less than 1 yr. Altered mental status, weakness, irritability, stupor, coma 5-30% of young patients who survive have permanent neurological deficits


Human WEE : Human WEE Prognosis Poor for young clinical patients Case-fatality rate: 3-15% Death within one week of clinical onset Diagnosis difficult from blood, CSF Postmortem virus isolation from brain Treatment is supportive care Vaccine available for military personnel only


Animal WEE : Animal WEE Asymptomatic Blacktail jackrabbit, kangaroo rat, Western gray squirrel, prairie dog, horse Horses with clinical signs Fever, depression, altered mentation, head pressing, ataxia, dysphagia Progress to paralysis, convulsions, death Mortality rate 20-50%


Animal WEE : Animal WEE Diagnosis Virus isolation from CSF in acute cases, blood in viremic cases Treatment is supportive care Prevention Immunize with inactivated vaccine Two shots, one month apart, booster every six months to a year Animals are good sentinels


St. Louis Encephalitis : St. Louis Encephalitis


SLE History : SLE History 1932 Human illness in Paris, IL 1933 Outbreak in St. Louis, MO 1,000 clinical cases - 20% mortality Virus isolated in human brain tissue 1940’s Culex tarsalis mosquito identified as the principal vector 1954 Culex pipiens-quinquefasciatus mosquitoes implicated in Texas


SLE History : SLE History 1964 Widespread outbreak in the U.S. From Houston, TX to Delaware River Valley 1975 Largest U.S. epidemic 1,800 cases Central U.S. from Canada to Texas Principal arbovirus problem in U.S.


SLE Transmission : SLE Transmission Vertebrate Hosts Dead-end hosts: Humans Culex tarsalis Primary Vector Transovarial Migratory birds Spring Introduction


SLE Transmission : SLE Transmission


SLE Epidemiology : SLE Epidemiology Epidemics cluster in towns and cities Mosquito and bird population Ideal to expose large groups of people 1:250 inapparent infection-to-case ratio Many cases undiagnosed Most cases Central and southern United States July-September Case-fatality rate: 5-15%


Slide64 : SLE in the U.S.: 1993-2002 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Year (Month) Reported Cases 60 45 30 15 0 Encephalitis/Meningitis, St. Louis. Reported cases-U.S, 1993-2002 MMWR


Human SLE : Human SLE Incubation period: 4-21 days Most cases asymptomatic Less than 1% of cases are clinically apparent Fever, headache, altered mental status 60% of patients have tremors Milder disease in children Elderly at highest risk for severe disease and death


Human SLE : Human SLE Diagnosis is by serology IgM antibody capture ELISA Virus only present in brain, spinal cord Increased corticosteroid production, hyponatremic, low cell number in CSF Treatment is supportive care Prognosis improves over time No vaccine available


Animal SLE : Animal SLE Birds Asymptomatic vertebrate hosts No known cause of illness in mammals other than humans


St. Louis Encephalitis Case : St. Louis Encephalitis Case August 1991: Pine Bluff, Arkansas Two people hospitalized Fever, encephalitis symptoms IgM to SLE in cerebrospinal fluid 24 patients total 14 females, 8 males All worked or resided in Pine Bluff 3 had neurological sequelae 1 died due to leukemia


Venezuelan Equine Encephalitis : Venezuelan Equine Encephalitis Peste loca, Derrengadera


Viral Strains : Viral Strains


VEE Viral Strains : VEE Viral Strains Epizootic/Epidemic I-A, I-B and I-C Disease in humans and horses Transmission by many mosquito species Natural reservoir unknown Horses and donkeys act as amplifiers Enzootic/Endemic Disease in humans Transmission mainly by Culex (Melanoconion) species Natural reservoir is rodents living in swamps and forests


VEE History : VEE History Western Hemisphere disease Primarily Central and South America 1938: Isolated from a horse brain 1962-1964 Outbreak in Venezuela 23,000 human cases 1967 Outbreak in Colombia 220,000 human cases Over 67,000 horse deaths


VEE History : VEE History 1969-1971 Largest recorded outbreak in Guatemala Area from Costa Rica to Rio Grande Valley in Texas Thousands of human encephalitis cases Over 100,000 horses died Small outbreaks occur occasionally 1995 Venezuela and Colombia Over 90,000 human cases


VEE Epizootic Transmission : VEE Epizootic Transmission Primary Vector multiple mosquito species Dead-end hosts: Humans Vertebrate Host: Horses Other species naturally infected but not amplifiers


VEE Enzootic Transmission : VEE Enzootic Transmission Primary Vector Culex (Melanoconion) species Dead end hosts: Humans Vertebrate Host: Rodents P. Myers


VEE Epidemiology : VEE Epidemiology 1971 Only U.S. outbreak - in Texas Enzootic variant Everglades virus in south Florida 2-3 human cases, no horse disease Infection in humans less severe than EEE or WEE Fatalities rare, less than 1%


Human VEE : Human VEE Initial signs Last 24-48 hours Fever, malaise, dizziness, chills, headaches, anorexia, severe myalgia, arthralgia, nausea, vomiting Lethargy and anorexia can last 2-3 weeks 4-15% of cases become neurological Mortality rates less than 1% Most often in children with encephalitis


Human VEE : Human VEE In utero death Possible in pregnant women who contract the disease Diagnosis Paired sera with rising titer ELISA IgG or IgM Treatment: Supportive care No vaccine available Prognosis Variable, often chronic fatigue and headaches


Animal VEE : Animal VEE Incubation period: 1-5 days Horses most susceptible Fever, anorexia, depression, flaccid lips, droopy eyelids and ears, incoordination and blindness Death 5-14 days after clinical onset Case-fatality rate: 38-83% In utero transmission results in abortion, stillbirth


Animal VEE : Animal VEE Most domestic animals do not show clinical signs or amplify the virus Experimentally Infected rabbits and dogs die after inoculation Laboratory animals susceptible Act as sentinels Guinea pigs, mice, hamsters Enzootic strains do not cause disease in animals


Animal VEE : Animal VEE Diagnosis Paired sera with rising titer ELISA IgG or IgM Treatment: Supportive care Vaccine available for horses Trivalent, formalin inactivated WEE, EEE, VEE combination Days 0 and 30 Annual or biannual booster


VEE as a Biological Weapon : VEE as a Biological Weapon Aerosolized VEE Human and equine disease occur simultaneously Flu-like symptoms in humans Possible neurological signs in horses Large number of cases in a given geographic area


Prevention and Control : Prevention and Control


Management of Mosquito-Borne Diseases : Management of Mosquito-Borne Diseases Source reduction Surveillance Biological control Chemical control Larvicide Adulticide Educating the public How to protect themselves


Source Reduction : Source Reduction Make habitats unavailable or unsuitable for egg laying and larval development Minimize irrigation and lawn watering Punch holes in old tires Fill tree holes with cement Clean bird baths, outside waterers, fountains


Source Reduction Cont’d : Source Reduction Cont’d Drain or fill temporary pools with dirt Keep swimming pools treated and circulating Avoid stagnant water Open marsh water management Connect to deep water habitats and flood occasionally Fish access


Surveillance : Surveillance Record keeping Weather data, mosquito larval populations, adult flight patterns Sentinel chicken flocks Blood test and utilize ELISA to monitor seroconversion of EEE, WEE, SLE


Surveillance : Surveillance Mosquito trapping and testing for viral presence


Biological Control : Biological Control Predators, natural and introduced, to eat larvae and pupae Mosquito fish Gambusia affinis, G. holbrooki most common Fundulus spp., Rivulus spp., killifish Other agents have been used but are not readily available Copepods


Chemical Control : Chemical Control Essential when source reduction is not enough or surveillance shows increased population of virus-carrying mosquitoes Requires properly trained personnel Larvicides, adulticides Toxic to many birds, fish, wildlife, aquatic invertebrates, honeybees Human exposure is uncommon


Chemical Control : Chemical Control Federal Food Drug and Cosmetic Act limits the quantity of adulticide used Due to wind drift onto agricultural crops Method used varies Type of target mosquito Type of targeted habitat Aerial spraying covers wide area Funding providing by state or local government Rarely federal


Larvicides : Larvicides Use when source reduction and biological control not feasible More effective and target-specific Less controversial than adulticides Applied to smaller geographic areas Larvae concentrate in specific locations


Larvicides : Larvicides


Adulticides : Adulticides Necessary when other control measures unsuccessful Least efficient Proper type and time of application helps efficacy Ultra low volume (ULV) foggers 1 ounce per acre Small droplets contact and kill adults


Adulticides : Adulticides


Personal Protection : Personal Protection Stay inside during the evening when mosquitoes are most active Wear long pants and sleeves Use mosquito repellent when necessary Follow label directions DEET Do not use on pets


Personal Protection : Personal Protection Make sure window and door screens are "bug tight" Replace your outdoor lights with yellow "bug" lights Bug zappers are not very effective ULV foggers for backyard use Keep vegetation and standing water in check around the dwelling


VEE as a Biological Weapon : VEE as a Biological Weapon 50 kg virulent VEE particles Aerosolized over city of 5 million people 150,000 people exposed 30,000 people ill 300 deaths


Internet Resources : Internet Resources CDC Division of Vector Borne Infectious Diseases-Arboviral Encephalitides www.cdc.gov/ncidod/dvbid/arbor/arbdet.htm American Mosquito Control Association www.mosquito.org


Acknowledgments : Acknowledgments Development of this presentation was funded by a grant from the Centers for Disease Control and Prevention to the Center for Food Security and Public Health at Iowa State University.


Acknowledgments : Acknowledgments Author: Co-author: Reviewer: Radford Davis, DVM, MPH Danelle Bickett-Weddle, DVM, MPH Jean Gladon, BS