An Outbreak of Japanese Encephalitis in Adults in Northern China, 2013: A Population-Based Study

Trends in temporal and spatial changes of Japanese encephalitis in Chinese mainland, 2004-2019: A population-based surveillance study

BACKGROUND

Japanese encephalitis (JE) is a serious health concern in China, with approximately 80 % of global infections occurring in China. To develop effective prevention and control strategies, this study explored the epidemiological characteristics of JE in China based on spatiotemporal data, to understand the patterns and trends of JE incidence in different regions and time periods.

METHOD

The incidence and mortality rates of JE were extracted from the Public Health Data Center, the official website of the National Health Commission of the People's Republic of China, and the National Notifiable Infectious Disease Surveillance System from 2004 to 2019. Joinpoint regression was applied to examine the spatiotemporal patterns and annual percentage change in incidence and mortality of the JE.

RESULTS

From 2004 to 2019, a total of 43,569 cases of JE were diagnosed, including 2081 deaths. The annual incidence rate of JE decreased from 0.4171/100,000 in 2004 to 0.0298/100,000 in 2019, with an annual percentage change (APC) of -13.5 % (P < 0.001). The annual mortality rate of JE showed three stages of change, with inflection points in 2006 and 2014. The incidence and mortality rates of JE have declined in all provinces of China, and more cases were reported in 0-14 years of age, accounting for nearly 80 % of all patients.

CONCLUSIONS

The morbidity and mortality rates of JE in China are generally on a downward trend, and emphasis should be placed on strengthening disease surveillance in special areas and populations, popularizing vaccination, and increasing publicity.

Incongruence between confirmed and suspected clinical cases of Japanese encephalitis virus infection

Background

Japanese encephalitis (JE) is a notifiable infectious disease in China. Information on every case of JE is reported to the superior health administration department. However, reported cases include both laboratory-confirmed and clinically diagnosed cases. This study aimed to differentiate between clinical and laboratory-confirmed cases of Japanese encephalitis virus (JEV) infection, and improve the accuracy of reported JE cases by analyzing the acute-phase serum and cerebrospinal fluid of all reported JE cases in the Sichuan province from 2012 to 2022.

Methods

All acute-phase serum and/or cerebrospinal fluid samples of the reported JE cases were screened for IgM(ImmunoglobulinM)to JEV using the enzyme-linked immunosorbent assay (ELISA), and the detection of the viral genes of JEV and 9 other pathogens including enterovirus (EV), using reverse transcription PCR was attempted. Epidemiological analyses of JE and non-JE cases based on sex, age, onset time, and geographical distribution were also performed.

Results

From 2012 to 2022, 1558 JE cases were reported in the Sichuan province. The results of serological (JEV-specific IgM) and genetic testing for JEV showed that 81% (1262/1558) of the reported cases were confirmed as JEV infection cases (laboratory-confirmed cases). Among the 296 cases of non-JEV infection, 6 viruses were detected in the cerebrospinal fluid in 62 cases, including EV and the Epstein-Barr virus (EBV), constituting 21% (62/296) of all non-JE cases. Among the 62 non-JEV infection cases with confirmed pathogens, infections with EV and EBV included 17 cases each, herpes simplex virus (HSV-1/2) included 14 cases, varicella- zoster virus included 6 cases, mumps virus included 2 cases, and human herpes viruses-6 included 1 case. Additionally, there were five cases involving mixed infections (two cases of EV/EBV, one case of HSV-1/HSV-2, one case of EBV/HSV-1, and one case of EV/herpes viruses-6). The remaining 234 cases were classified as unknown viral encephalitis cases. Our analysis indicated that those aged 0-15 y were the majority of the patients among the 1558 reported JE cases. However, the incidence of laboratory-confirmed JE cases in the >40 y age group has increased in recent years. The temporal distribution of laboratory-confirmed cases of JE revealed that the majority of cases occurred from May to September each year, with the highest incidence in August.

Conclusion

The results of this study indicate that there is a certain discrepancy between clinically diagnosed and laboratory-confirmed cases of JE. Each reported case should be based on laboratory detection results, which is of great importance in improving the accuracy of case diagnosis and reducing misreporting. Our results are not only important for addressing JE endemic to the Sichuan province, but also provide a valuable reference for the laboratory detection of various notifiable infectious diseases in China and other regions outside China.

Japanese encephalitis transmission trends in Gansu, China: A time series predictive model based on spatial dispersion

Objective

This study serves to ascertain trends of space and time for Japanese encephalitis (JE) transmission at the township-level and develop an innovative time series predictive model to predict the geographical spread of JE in Gansu Province, China.

Methods

We collected weekly data on JE from 2005 to 2019 at the township-level. Kriging interpolation maps were used to visualize the trend of the epidemic spread of JE, and linear regression models were used to calculate the monthly changes in minimum longitude and maximum latitude of emerging towns with JE to assess the speed of the epidemic's spread to the northwest. Additionally, we utilized a time series Seasonal Autoregressive Integrated Moving Average (SARIMA) model to dynamically predict the ongoing weekly number of JE emerging townships.

Results

The Kriging difference map revealed a significant trend of JE spread towards the northwest. Our regression model indicated that the rate of decrease in minimum longitude was approximately 0.64 km per month, while the rate of increase in maximum latitude was approximately 1.00 km per month. Furthermore, the SARIMA pattern (2,0,0)(2,0,1)₅₂ exhibited a better goodness-of-fit for predicting JE transmission, with an overall agreement of 93.27% to 94.23%.

Conclusion

Our study highlights the expansion of JE cases towards the northwest of Gansu, indicating the need for ongoing surveillance and control efforts. The use of the SARIMA model provides a valuable tool for predicting the trend of JE spatial dispersion, thereby improving early warning systems. Our findings suggest that the number of emerging townships can be used to predict the trend of JE spatial dispersion, providing crucial insights for future research on JE incidence.

Tracing the spatiotemporal phylodynamics of Japanese encephalitis virus genotype I throughout Asia and the western Pacific

BACKGROUND

Japanese encephalitis virus (JEV; Flaviridae: Flavivirus) causes Japanese encephalitis (JE), which is the most important arboviral disease in Asia and the western Pacific. Among the five JEV genotypes (GI-IV), GI has dominated traditional epidemic regions in the past 20 years. We investigated the transmission dynamics of JEV GI through genetic analyses.

METHODS

We generated 18 JEV GI near full length sequences by using multiple sequencing approaches from mosquitoes collected in natural settings or from viral isolates obtained through cell culture. We performed phylogenetic and molecular clock analyses to reconstruct the evolutionary history by integrating our data with 113 publicly available JEV GI sequences.

RESULTS

We identified two subtypes of JEV GI (GIa and GIb), with a rate of 5.94 × 10-4 substitutions per site per year (s/s/y). At present, GIa still circulates within a limited region, exhibited no significant growth, the newest strain was discovered in China (Yunnan) in 2017, whereas most JEV strains circulating belong to the GIb clade. During the past 30 years, two large GIb clades have triggered epidemics in eastern Asia: one epidemic occurred in 1992 [95% highest posterior density (HPD) = 1989-1995] and the causative strain circulates mainly in southern China (Yunnan, Shanghai, Guangdong, and Taiwan) (Clade 1); the other epidemic occurred in 1997 (95% HPD = 1994-1999) and the causative strain has increased in circulation in northern and southern China during the past 5 years (Clade 2). An emerging variant of Clade 2 contains two new amino acid markers (NS2a-151V, NS4-169K) that emerged around 2005; this variant has demonstrated exponential growth in northern China.

CONCLUSION

JEV GI stain circulating in Asia have shifted during the past 30 years, spatiotemporal differences were observed among JEV GI subclade. GIa is still circulating within a limited range, exhibite no significant growth. Two large GIb clades have triggered epidemics in eastern Asia, all JEV sequences identified in northern China during the past 5 years were of the new emerging variant of G1b-clade 2.

Mosquito swarm counting via attention-based multi-scale convolutional neural network

Monitoring mosquito density to predict the risk of transmission of the virus and develop a response in advance is an important part of prevention efforts. This paper aims to estimate accurately the mosquito swarm count from a given image. To this end, we proposed an attention-based multi-scale mosquito swarm counting model that consists of the feature extraction network (FEN) and attention based multi-scale regression network (AMRN). The FEN uses VGG-16 network to extract low-level features of mosquitoes. The AMRN adopts a multi-scale convolutional neural network, and with a squeeze and excitation channel attention module in the branch with a 7 × 7 convolution kernel to extract high-level features, map the feature map to the mosquito swarm density map and estimate mosquitoes count. We collected and labelled a data set that includes 391 mosquito swarm images with 15,466 mosquitoes. Experiments show that our method performs well on the data set and achieves mean absolute error (MAE) of 1.810 and root mean square error (RMSE) of 3.467.

A comparison of clinical manifestations of Japanese encephalitis between children and adults in Gansu Province, Northwest China (2005-2020)

Japanese encephalitis (JE), a mosquito-borne zoonotic disease, has emerged as a major public health concern around the world. Previous research has shown that JE has serious sequelae, and the recent shift in the population from children to adults presents a significant challenge for JE treatment and prevention. Therefore, we examined the differences in clinical manifestations (clinical symptoms, clinical signs, complications, and clinical typing) of JE between children and adults over the 15 years in Gansu Province to provide a theoretical basis for better response to JE treatment. Clinical typing was found to be statistically significant in the child versus adult groups and the groups with or without vaccination. Only the dysfunction of consciousness differed statistically between children with and without vaccination, whereas neurological symptoms such as vomiting (jet vomiting), irritability, drowsiness, convulsions, and hyperspasmia differed statistically between children and adults, and the rest of the symptoms did not differ statistically. Only pupil size changes were statistically different in clinical signs between the children with and without vaccination, while blood pressure changes, change in pupil size, positive meningeal stimulation signs, and positive pathological reflexes (increased muscle tone and Babinski's sign) were statistically different between adults and children. Bronchopneumonia was the most common complication, especially in adults. Therefore, the authors believe that children and adults differ in some clinical manifestations and propose that efforts should be directed toward developing individualized treatment plans for different age groups and employing more effective supportive treatment for various populations. In addition, we suggest expanding the coverage of the JE vaccine and increasing overall vaccination rates and adopting multiple measures in conjunction with JE prevention and control.

Environmental factors and spatiotemporal distribution of Japanese encephalitis after vaccination campaign in Guizhou Province, China (2004-2016)

Background

Although a vaccination campaign has been conducted since 2004, Japanese encephalitis (JE) is still a public health problem in Guizhou, one of the provinces with the highest incidence of JE in China. The aim of this study was to understand the spatiotemporal distribution of JE and its relationship with environmental factors in Guizhou Province in the post-vaccination era, 2004–2016.

Methods

We collected data on human JE cases in Guizhou Province from 2004 to 2016 from the national infectious disease reporting system. A Poisson regression model was used to analyze the relationship between JE occurrence and environmental factors amongst counties.

Results

Our results showed that the incidence and mortality of JE decreased after the initiation of vaccination. JE cases were mainly concentrated in preschool and school-age children and the number of cases in children over age 15 years was significantly decreased compared with the previous 10 years; the seasonality of JE before and after the use of vaccines was unchanged. JE incidence was positively associated with cultivated land and negatively associated with gross domestic product (GDP) per capita, vegetation coverage, and developed land. In areas with cultivated land coverage < 25%, vegetation coverage > 55%, and urban area coverage > 25%, the JE risk was lower. The highest JE incidence was among mid-level GDP areas and in moderately urbanized areas.

Conclusions

This study assessed the relationship between incidence of JE and environmental factors in Guizhou Province. Our results highlight that the highest risk of JE transmission in the post-vaccination era is in mid-level developed areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06857-3.

Monitoring Mosquito-Borne Arbovirus in Various Insect Regions in China in 2018

Background

Increases in global travel and trade are changing arbovirus distributions worldwide. Arboviruses can be introduced by travelers, migratory birds, or vectors transported via international trade. Arbovirus surveillance in field-collected mosquitoes may provide early evidence for mosquito-borne disease transmission.

Methods

During the seasons of high mosquito activity of 2018, 29,285 mosquitoes were sampled from seven sentinel sites in various insect regions. The mosquitoes were analyzed by RT-PCR for alphaviruses, flaviviruses, and orthobunyaviruses.

Results

We detected three strains of Japanese encephalitis virus (JEV), five strains of Getah virus (GETV), and 45 strains of insect-specific flaviviruses including Aedes flavivirus (AeFV, 1), Chaoyang virus (CHAOV, 1), Culex flavivirus (CxFV, 17), Hanko virus (HANKV, 2), QuangBinh virus (QBV, 22), and Yunnan Culex flavivirus (YNCxFV, 2). Whole genomes of one strain each of GETV, CxFV, CHAOV, and AeFV were successfully amplified. Phylogenetic analysis revealed that the new JEV strains detected in the Shanghai and Hubei Provinces belong to the GI-b strain and are phylogenetically close to the NX1889 strain (MT134112) isolated from a patient during a JE outbreak in Ningxia in 2018. GETVs were found in Inner Mongolia, Hubei, and Hainan and belonged to Group III. They were closely related to strains isolated from swine. HANKV was recorded for the first time in China and other ISFVs were newly detected at several sentinel sites. The bias-corrected maximum likelihood estimation value for JEV in Jinshan, Shanghai was 4.52/1,000 (range 0.80-14.64). Hence, there is a potential risk of a JEV epidemic in that region.

Conclusion

GI-b is the dominant circulating JEV genotype in nature and poses a health risk to animals and humans. The potential threat of widespread GETV distribution as a zoonosis is gradually increasing. The present study also disclosed the dispersion and host range of ISFVs. These findings highlight the importance of tracing the movements of the vectors and hosts of mosquito-borne pathogens in order to prevent and control arbovirus outbreaks in China.

Neutralizing antibody rather than cellular immune response is maintained for nearly 20 years among Japanese encephalitis SA14-14-2 vaccinees in an endemic setting

Japanese encephalitis (JE), caused by infection with Japanese encephalitis virus (JEV), is the most important viral encephalitis in Asia. JE incidence has significantly decreased by immunization with live-attenuated vaccine SA14-14-2. However, the duration of immune response overtime after vaccination is inconclusive and may be associated with the risk of JE occurrence in adults. A cross-sectional study was conducted in 961 JE-vaccinated local residents aged 19-20 years in Beijing, China. 620 (65%) and 513 (53%) individuals were anti-JEV IgG antibody and neutralizing antibody (nAb) positive, respectively. The geometric mean titer (GMT) of nAb was 1:11, suggesting a seroprotection among the study population. As for IFN-γ production, peripheral blood mononuclear cell (PBMC) samples isolated from 60 subjects showed negative response following the stimulation with concentrated JEV particles. Overall, longer persistence of nAb response among vaccinees is observed than that of cellular immune response after 17-18 years of vaccination. Taken together, our results not only provide the data for evaluating herd immunity against JEV among vaccinated adults in Beijing but also offer useful information for JE prevention and control in endemic areas.

An outbreak of Japanese encephalitis caused by genotype Ib Japanese encephalitis virus in China, 2018: A laboratory and field investigation

Although Japanese encephalitis virus genotype Ib (JEV GIb) has replaced JEV GIII as the dominant genotype in endemic areas of Asia, no JEV GIb has been isolated from JE cases and natural mosquitoes at the same time in an outbreak of JE. In this study, we conducted virological and molecular biological laboratory tests on JE case samples (serum/cerebrospinal fluid) and locally collected mosquito samples from the 2018 JE outbreak in Ningxia, China. The result of JEV IgM antibody detection showed that 96% (67/70) of the suspected cases were laboratory-confirmed JE cases. Of the mosquitoes collected from local environments, 70% (17400/24900) were Culex tritaeniorhynchus of which 4.6% (16 /348 of the pools tested) were positive for JEV, other mosquitoes were negative. JEVs isolated from both the human cases and C. tritaeniorhynchus specimens belong to JEV GIb and are in the same evolutionary clade according to molecular evolution analyses.

JEV GIb was detected simultaneously from specimens of JE cases and mosquito samples collected in nature in this study, suggesting that the JE outbreak that occurred in Ningxia in 2018 was due to infection of JEV GIb.

Japanese encephalitis virus (JEV) is recognized as an important encephalitis pathogen all over the world. Its genotype is divided into GI-V. In recent years, JEV GIb (a temperate genotype) has gradually replaced GIII as the prevalent strain in JE endemic areas. Although JEV GIb originated from tropical Asia along with JEV GIa, it has rapidly spread for its advantages in wintering and infecting vectors. Although there have been epidemics caused by JEV GI and GIII, there have been no reports of a JE outbreak caused by JEV GIb alone in northeastern Asia. However, a JE outbreak occurred in the Ningxia Hui Autonomous Region in northern China in summer 2018 which was the first outbreak in Ningxia in recent decades. This paper presents a series of laboratory and field studies of this outbreak. The strain isolated from JE cases as well as JEV detected in Culex tritaeniorhynchus collected from local areas in nature all belonged to JEV GIb and were in the same evolutionary clade. This is the first report of a JE outbreak caused by JEV GIb infection in northeastern Asia (latitude 35 ° 14’– 39 ° 23’ N, longitude 104 ° 17’– 107 ° 39’ E), which used to be a low endemic area of JEV GIII.