West Nile virus surveillance using sentinel birds: results of eleven years of testing in corvids in a region of northern Italy

The natural transmission cycle of West Nile virus (WNV) involves birds as primary hosts and mosquitoes as vectors, but this virus can spread to mammals, human beings included. Asymptomatic infected donors pose a risk to the safety of blood transfusions and organ transplants, as WNV can be transmitted through these medical procedures. Since 2009, the region of Emilia-Romagna in northern Italy has been implementing an integrated surveillance system in order to detect WNV circulation in the environment at an early stage. Here we report the results of the two components of the surveillance system, the active testing of corvids and humans, and demonstrate that bird surveillance alone improves a surveillance system based solely on human case detection. As WNV risk reduction measures are applied on a provincial basis, we assessed the ability of this surveillance system component to detect virus circulation prior to the notification of the first human case for each province. Overall, 99 epidemic seasons were evaluated as a result of 11 years (2013-2023) of surveillance in the nine provinces of the region. In this period, 22,314 corvids were tested for WNV and 642 (2.9%) were found to be infected. WNV was generally first detected in birds in July, with sample prevalence peaks occurring between August and September. During the same period, 469 autochthonous human cases were notified, about 60% of which were reported in August. WNV was detected 79 times out of the 99 seasons considered. The virus was notified in birds 73 times (92.4%) and 60 times (75.9%) in humans. WNV was first or only notified in birds in 57 seasons (72.1%), while it was first or only notified in humans in 22 seasons (27.8%). Active surveillance in corvids generally allows the detection of WNV before the onset of human cases. Failure of virus detection occurred mainly in seasons where the number of birds tested was low. Our results show that active testing of a minimum of 3.8 corvids per 100 km2 provides a satisfactory timeliness in the virus detection, but for early detection of WNV it is crucial to test birds between mid-June and mid-August.

The Degree of One Health Implementation in the West Nile Virus Integrated Surveillance in Northern Italy, 2016

West Nile virus (WNV) is endemic in the Po valley area, Northern Italy, and within the legal framework of the national plan for the surveillance of human vector-borne diseases, WNV surveillance has over time been implemented. The surveillance plans are based on the transdisciplinary and trans-sectorial collaboration between regional institutions involved in public, animal, and environmental health. This integrated surveillance targets mosquitoes, wild birds, humans, and horses and aims at early detecting the viral circulation and reducing the risk of infection in the human populations. The objective of our study was to assess the degree of One Health (OH) implementation (OH-ness) of the WNV surveillance system in three North Italian regions (Emilia-Romagna, Lombardy, Piedmont) in 2016, following the evaluation protocol developed by the Network for Evaluation of One Health (NEOH). In detail, we (i) described the OH initiative (drivers, outcomes) and its system (boundaries, aim, dimensions, actors, stakeholders) and (ii) scored different aspects of this initiative (i.e., OH-thinking, -planning, -sharing, -learning, transdisciplinarity and leadership), with values from 0 (=no OH approach) to 1 (=perfect OH approach). We obtained a mean score for each aspect evaluated. We reached high scores for OH thinking (0.90) and OH planning (0.89). Lower scores were attributed to OH sharing (0.83), transdisciplinarity and leadership (0.77), and OH learning (0.67), highlighting some critical issues related to communication and learning gaps. The strengths and weaknesses detected by the described quantitative evaluation will be investigated in detail by a qualitative evaluation (process evaluation), aiming to provide a basis for the development of shared recommendations to refine the initiative and conduct it in a more OH-oriented perspective.

West Nile Virus Surveillance in 2013 via Mosquito Screening in Northern Italy and the Influence of Weather on Virus Circulation

West Nile virus (WNV) is a recently re-emerged health problem in Europe. In Italy, an increasing number of outbreaks of West Nile disease, with occurrences of human cases, have been reported since 2008. This is particularly true in northern Italy, where entomological surveillance systems have been implemented at a regional level. The aim of this study was to use, for the first time, all the entomological data collected in the five regions undergoing surveillance for WNV in northern Italy to characterize the viral circulation (at a spatial and temporal scale), identify potential mosquito vectors, and specify relationships between virus circulation and meteorological conditions. In 2013, 286 sites covering the entire Pianura Padana area were monitored. A total of 757,461 mosquitoes were sampled. Of these, 562,079 were tested by real-time PCR in 9,268 pools, of which 180 (1.9%) were positive for WNV. The largest part of the detected WNV sequences belonged to lineage II, demonstrating that, unlike those in the past, the 2013 outbreak was mainly sustained by this WNV lineage. This surveillance also detected the Usutu virus, a WNV-related flavivirus, in 241 (2.6%) pools. The WNV surveillance systems precisely identified the area affected by the virus and detected the viral circulation approximately two weeks before the occurrence of onset of human cases. Ninety percent of the sampled mosquitoes were Culex pipiens, and 178/180 WNV-positive pools were composed of only this species, suggesting this mosquito is the main WNV vector in northern Italy. A significantly higher abundance of the vector was recorded in the WNV circulation area, which was characterized by warmer and less rainy conditions and greater evapotranspiration compared to the rest of the Pianura Padana, suggesting that areas exposed to these conditions are more suitable for WNV circulation. This observation highlights warmer and less rainy conditions as factors able to enhance WNV circulation and cause virus spillover outside the sylvatic cycle.

Emergence of Equine West Nile Encephalitis in Central Macedonia, Greece, 2010

During the summer of 2010, an outbreak of West Nile virus (WNV) infections attributed to a lineage 2 WNV strain was reported among humans and horses in Central Macedonia, Northern Greece. Here, the clinical and laboratory investigation of horses that showed severe neurological signs due to WNV infection is being described. Specifically, between August and September 2010, 17 horses with neurological signs were detected. WNV infection was confirmed in all 17 clinical cases by applying laboratory testing. The duration of WNV-specific IgM antibodies in sera obtained from seven of the clinically affected horses was relatively short (10-60 days; mean 44 days). In the regional unit of Thessaloniki, (i) seroprevalence of WNV and fatality rate in horses were high (33% and 30%, respectively), and (ii) the ratio of neurological manifestations-to-infections for this virus strain was high (19%). These observations indicate that the strain responsible for the massive human epidemic of 2010 in Greece was also highly pathogenic for horses. This is the first time that WNV infection has been documented in horses with clinical manifestations in Greece. WNV infection should be included in the differential diagnosis of horses with encephalitis in Greece.

Usutu virus persistence and West Nile virus inactivity in the Emilia-Romagna region (Italy) in 2011

BACKGROUND

The circulation of West Nile virus and Usutu virus was detected in the Emilia-Romagna region in 2008 and 2009. To evaluate the extent of circulation of both viruses, environmental surveillance, based on bird and mosquito testing, was conducted in 2008 and gradually improved over the years.

METHODS

In February-March 2009-2011, 5,993 hibernating mosquitoes were manually sampled, out of which 80.1% were Culex pipiens; none tested positive for the viruses. From 2008 to 2011, 946,213 mosquitoes, sampled between May and October, were tested; 86.5% were Cx. pipiens. West Nile virus was detected in 32 Cx. pipiens pools, and Usutu virus was detected in 229 mosquito pools (217 Cx. pipiens, 10 Aedes albopictus, one Anopheles maculipennis s.l., and one Aedes caspius). From 2009 to 2011, of 4,546 birds collected, 42 tested positive for West Nile virus and 48 for Usutu virus. West Nile virus and Usutu virus showed different patterns of activity during the 2008-2011 surveillance period. West Nile virus was detected in 2008, 2009, and 2010, but not in 2011. Usutu virus, however, was continuously active throughout 2009, 2010, and 2011.

CONCLUSIONS

The data strongly suggest that both viruses overwinter in the surveyed area rather than being continually reintroduced every season. The lack of hibernating mosquitoes testing positive for the viruses and the presence of positive birds sampled early in the season support the hypothesis that the viruses overwinter in birds rather than in mosquitoes. Herd immunity in key bird species could explain the decline of West Nile virus observed in 2011, while the persistence of Usutu virus may be explained by not yet identified reservoirs. Reported results are comparable with a peri-Mediterranean circulation of the West Nile virus lineage 1 related strain, which became undetectable in the environment after two to three years of obvious circulation.

West Nile virus in north-eastern Italy, 2011: entomological and equine IgM-based surveillance to detect active virus circulation

Since 2008, West Nile Virus (WNV) has expanded its range in several Italian regions, and its yearly recurrence suggests the virus may have become endemic in some areas. In 2011, a new plan based also on the detection of IgM antibodies was implemented in the north-eastern Italian regions of Veneto and Friuli Venezia Giulia, aiming to early detect WNV infections in areas where the virus had already circulated during the previous summers, and in adjacent zones. From July to November 2011, 1880 sera from 521 equine premises were screened by a commercial IgM capture ELISA. Mosquitoes were captured by CDC-CO2 traps at 61 locations in the two regions. Collected mosquitoes were identified, pooled by species/date/location and examined by real-time RT-PCR and sequencing. Passive surveillance was carried out on clinically affected horses and non-migratory wild birds found dead. IgM sero-positive equines were detected in 19 holdings, five in the area with WNV circulation (AWC) and 14 in the surveillance area (SA); 10 more horse premises tested positive to further serological controls within 4 km of the positive holdings. A total of 85,398 mosquitoes of 15 species were collected and 2732 pools examined. Five Culex pipiens pools tested positive for the presence of WNV. Passive surveillance on non-migratory wild birds allowed detection of the virus only in one found dead collared dove (Streptopelia decaocto), of 82 birds sampled. The WNV belonged to the lineage 2, which had been isolated for the first time in Italy earlier in 2011. By the first week of October, nine human cases had been confirmed in the same area. The implementation of a protocol combining IgM screening of horses with surveillance on mosquito vectors proved to be valuable for early detecting WNV circulation.

Seasonal pattern of daily activity of Aedes caspius, Aedes detritus, Culex modestus, and Culex pipiens in the Po Delta of northern Italy and significance for vector-borne disease risk assessment

The increasing concern about vector-borne diseases such as West Nile disease in northern Italy motivated our analysis of data on the mosquito fauna and the seasonal and daily flight patterns collected in 1998 in the Po Valley. Collections were performed once a week from May to November, with human landing collections and CO(2) traps. Culex pipiens was present from July to October and showed a clearly unimodal nocturnal flight habit. Culex modestus appeared in July-August and showed a bimodal flight pattern, (main peak during the evening and a minor one in the morning). Aedes caspius was present from May to November (highest densities in July-August) and showed a bimodal flight pattern with a major crepuscular peak and a minor dawn peak in the morning. Aedes detritus was the most abundant species in May, with a crepuscular sharply bimodal flight pattern, particularly according to human landing collections. Sunset and sunrise time, in combination with the solar phase (that determines daylight duration and its trend of changing) were the main factors affecting flight behavior. Temperature, relative humidity, and wind speed differently affected the flight behavior of mosquito females according to the species.

Mosquito, bird and human surveillance of West Nile and Usutu viruses in Emilia-Romagna Region (Italy) in 2010

Background

In 2008, after the first West Nile virus (WNV) detection in the Emilia-Romagna region, a surveillance system, including mosquito- and bird-based surveillance, was established to evaluate the virus presence. Surveillance was improved in following years by extending the monitoring to larger areas and increasing the numbers of mosquitoes and birds tested.

Methodology/Principal Findings

A network of mosquito traps, evenly distributed and regularly activated, was set up within the surveyed area. A total of 438,558 mosquitoes, grouped in 3,111 pools and 1,276 birds (1,130 actively sampled and 146 from passive surveillance), were tested by biomolecular analysis. The survey detected WNV in 3 Culex pipiens pools while Usutu virus (USUV) was found in 89 Cx. pipiens pools and in 2 Aedes albopictus pools. Two birds were WNV-positive and 12 were USUV-positive. Furthermore, 30 human cases of acute meningoencephalitis, possibly caused by WNV or USUV, were evaluated for both viruses and 1,053 blood bags were tested for WNV, without any positive result.

Conclusions/Significance

Despite not finding symptomatic human WNV infections during 2010, the persistence of the virus, probably due to overwintering, was confirmed through viral circulation in mosquitoes and birds, as well as for USUV. In 2010, circulation of the two viruses was lower and more delayed than in 2009, but this decrease was not explained by the relative abundance of Cx. pipiens mosquito, which was greater in 2010. The USUV detection in mosquito species confirms the role of Cx. pipiens as the main vector and the possible involvement of Ae. albopictus in the virus cycle. The effects of meteorological conditions on the presence of USUV-positive mosquito pools were considered finding an association with drought conditions and a wide temperature range. The output produced by the surveillance system demonstrated its usefulness and reliability in terms of planning public health policies.

Retrospective diagnosis of West Nile virus infection in a patient with meningoencephalitis in Tuscany, Italy

We report a case of West Nile virus (WNV) infection in a symptomatic woman living in Tuscany in 2007. A retrospective analysis on cerebrospinal fluids drawn from people affected by neurological diseases with unknown etiology allowed the identification of a case of WNV infection before the WNV outbreak in the Northeast Italy in 2008. This emphasizes the importance of maintaining a high level of epidemiological surveillance all over the Italian territory.

Climate changes, environment and infection: facts, scenarios and growing awareness from the public health community within Europe

Climate change is a current global concern and, despite continuing controversy about the extent and importance of causes and of its effects, it seems likely that it will affect the incidence and prevalence of both residual and imported infections in Europe. Climate affects mainly the range of infectious diseases, whereas weather affects the timing and intensity of outbreaks. Climate change scenarios include a change distribution of infectious diseases with warming and changes in outbreaks associated with weather extremes. The largest health impact from climate change for Europe doesn't come from vector borne infectious diseases. This does not mean that these types of health impacts will not arise in Europe. The ranges of several vector-borne diseases or their vectors are already changing in altitude due to warming. In addition, more intense weather events create conditions conductive to outbreaks of infectious diseases: Heavy rains leave insect breeding sites, drive rodents from burrows, and contaminate clean water systems. The incidence of mosquito-borne parasitic and viral diseases, are among those diseases most sensitive to climate. Climate change affect disease transmission by shifting the vector's geographic range and by shortening the pathogen incubation period. climate-related increases in temperature in sea surface and level would lead to higher incidence of waterborne infectious and toxin-related illnesses, such as cholera and seafood intoxication. Climate changes all around the world with impact in Europe are demonstrated by the fact that recent cases of cholera have been imported to Europe from Kenya, where spreading epidemic has been linked to the El Niño phenomenon, originated from the Pacific Ocean. Human migration and damage to health infrastructures from aberrant climate changes could indirectly contribute to disease transmission. Human susceptibility to infections might be further compounded by alterations in the human immune system caused by increased exposure to ultraviolet radiation and malnutrition due to alterations in agricultural products. Different kind of incidents in Europe with extreme weather events demonstrated effects on public health. The recent outbreak of the insect-borne Chikungunya virus in Italy in 2007 is an example of the kind of new health threat that the EU must be vigilant to confront. In addition, health effects of flooding, have been related to an excess cases of leptospirosis and campylobacter enteritis. Such examples have been demonstrated reported after flooding in the Czech Republic. Similarly, an increase of cryptosporidiosis in the United Kingdom has been related to flooding. Changing vector distributions associated with tickborne encephalitis and malaria have also been demonstrated in EU. A recently reported case of malaria in Italy in June 2008, suspected to be indigenously acquired, has shown how easily malaria could be reintroduced into several countries in the region. Another case of malaria in Greece in May 2010 affecting a young man living in a forestry region was claimed at KEELPNO-the Greek Center for disease control. Would this latest case be considered closely related to the one from Italy? If yes, then Public Health Services should elaborate plans to affront possible tickborne diseases. Heat waves are important causes of mortality on mortality are important. The deaths seen in France in 2003 from a heat wave are projected to be repeated, as heat waves become more severe. However, heat waves impacts on the transmission and severity of infectious diseases have not been elucidated. Finally scientific challenges include the elucudation of climate changes and extreme weather condition impact on infection transmission and outcome, human immune system changes and infection response, outbreak scenarios, animal and plant health and public health preparedness. European action plans to affront climate changes related health and infection problems are developed by the EU Commission at different levels and jointly by different DGs. In a few words within the EU the following points on human, animal and plant health are considered a priority: * Strengthening cooperation between the services of these three branches of health (human, animals, plants); * Developing action plans in the event of extreme weather conditions, in order to be better prepared and to react in the best way; * Gathering more reliable information on the risks of climate change whilst maintaining international cooperation, in particular with the WHO, as cooperation beyond that between Member States will be required to be more effective; * Providing additional effort to identify the most effective measures; * Improving the surveillance and the control of the animal diseases. The European Commission has decided to consider climate change, and the consequences it has on health, with greater importance whilst being aware that it is at the root of numerous diseases.

Phylogeography and epidemiological history of West Nile virus genotype 1a in Europe and the Mediterranean basin

Aim of this study was to reconstruct the temporal and spatial phylodynamics of WNV-1a, the genotype to which the majority of European/Mediterranean viral strains belongs, by using sequences retrieved from public databases. WNV-1a isolates segregated into two major clades: the recent West Mediterranean sequences formed a single monophyletic group within clade A. Clade B included sequences from East Mediterranean and America. Phylogeographic analysis suggested that WNV-1a probably originated in sub-Saharan Africa in the early XXth century, and then spread northwards since the late 1970s, via two routes: one crossing Eastern Mediterranean and the other the Western Mediterranean countries. Our data suggest that the circulation of the virus in a given geographical area usually precedes the onset of the outbreak by one year or more, and underline the importance of the spatial-temporal phylodynamics reconstruction in clarifying the recent epidemiology and in setting up an efficient surveillance system for emerging/reemerging zoonosis.

Two new real-time quantitative reverse transcription polymerase chain reaction assays with unique target sites for the specific and sensitive detection of lineages 1 and 2 West Nile virus strains

Two novel 1-step real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR) assays for the simultaneous detection of West Nile virus (WNV) lineage 1 and 2 strains were developed. Primers and the probe of assay 1 target the 5'-untranslated region (UTR), whereas the amplicon of assay 2 is located in the nonstructural region NS2A, which enables an unambiguous and independent WNV diagnosis based on 2 different amplicons. Both assays allow the detection of as few as 2-4 genome copies of WNV strains NY99, Uganda B956, Kunjin, and Sarafend (all cultured on Vero cells). A new synthetic RNA mutant of the 5'-UTR amplicon, which contains 6 twist inverted base-pair changes at the probe attachment site, was used as external calibrator control.

West Nile virus circulation in Veneto region in 2008-2009

West Nile virus (WNV) was detected in Italy, in late summer 2008 in horses and birds in the Po valley. As a consequence, an intense WNV surveillance was implemented in that area involving Emilia-Romagna, Veneto and Lombardy. This paper presents the results of the September 2008-November 2009 surveillance on equines, mosquitoes, wild birds, dogs and cattle in Veneto. WNV was detected in equines and dogs, and, to a lesser extent in cattle and wild birds. Simultaneous circulation of Usutu virus was detected by testing wild birds found dead. Usutu virus but not WNV was also found in mosquitoes monitored during 2009. Equine practices monitoring allowed the definition of an area of WNV circulation and the 2008-2009 westward and northward spread of the infection. Although a relatively low number of human cases and a low virus circulation in vectors and birds detected in Veneto region could be considered favourable conditions for a limited risk of human exposure, it remains difficult to predict the possible evolution of the epidemiological situation.

Effects of temperature and rainfall on the activity and dynamics of host-seeking Aedes albopictus females in northern Italy

The Asian tiger mosquito, Aedes albopictus, has colonized nearly all the regions of Italy as well as other areas of Europe. During the summer of 2007 the tiger mosquito was responsible for an outbreak of Chikungunya in Italy, when this virus was brought in by a tourist of Indian origin returning from an endemic area. To increase the knowledge of tiger mosquito population dynamics, a survey was carried out from April to November 2008 in the municipalities of Arco and Riva del Garda (northern Italy) through a Biogents Sentinel™ (BG)-trap sampling. In particular, the aim of the study was to evaluate the influence of temperature and rainfall on the activity and dynamics of A. albopictus host-seeking females. The seasonal emergence of host-seeking females was strongly influenced by the minimum temperature, and a lower threshold of 13°C was identified. In addition, the threshold for the end of adult activity was found at a minimum temperature of 9°C. Host-seeking female abundance was positively affected by the accumulated temperatures over the period 3 and 4 weeks before the sampling week, possibly as a consequence of the positive effect of accumulated temperatures on larval density. Instead, accumulated precipitation over 1-4 weeks before sampling was negatively correlated with host-seeking female abundance. Finally, the activity of host-seeking females, estimated by the weekly increment in female abundance, was positively affected by the total abundance of females and by mean weekly temperatures. Our study provides useful information for predicting the dynamics of host-seeking Ae. albopictus females in northern Italy and for designing control strategies for preventing arbovirus outbreaks in areas colonized by Ae. albopictus.

Is Culex modestus (Diptera: Culicidae), vector of West Nile virus, spreading in the Dombes area, France?

As a main vector of West Nile (WN) virus (family Flaviviridae, genus Flavivirus) in Europe, Culex modestus Ficalbi (Diptera: Culicidae) is commonly found in delta regions, lakes, and ponds. The Dombes area is located along one of the main corridors of bird migrations in France and lies 300 km north of the Camargue region, a frequent focus of WN virus circulation. It is an important breeding, wintering, and stopover site for many bird species that are putative carriers of viruses of different kinds. It is also a continental wetland with approximately =1200 fish farming ponds, scattered over the area, that provide suitable breeding sites for Cx. modestus. This article reports an entomological study based on larval surveys conducted in ponds in 2007 to assess the prevalence and abundance of Cx. modestus in the Dombes. Using the larval survey as an ecological screening test, we investigated the proportion of ponds found positive for Cx. modestus, and the relative abundance of this species was estimated in larval samples. We found that its pond distribution was more extensive in the 2007 survey than in that conducted in the 1970s. Survey methods and meteorological and anthropological factors that could account for the differences or variations between the findings of the two investigations are discussed.