Arboviral Disease Outbreaks in the Pacific Islands Countries and Areas, 2014 to 2020: A Systematic Literature and Document Review

A Review of the Recent Epidemiology of Zika Virus Infection

Zika virus (ZIKV) is a flavivirus transmitted primarily by the bite of infected Aedes species mosquitoes. Although typically asymptomatic or causing mild symptoms and infrequent neurological disease in older children and adults, infection during pregnancy can result in severe congenital malformations and neurodevelopmental deficits. We conducted a review of published literature and official data sources to describe recent Zika epidemiological trends, building on WHO updates posted in 2019 and 2022. Globally, cases declined after the height of ZIKV transmission in the Americas in 2015-2016; however, transmission continues across multiple regions, with intermittent outbreaks reported. As of December 2023, there is documented evidence of current or prior autochthonous mosquito-borne ZIKV transmission in 92 countries and territories; most recently, Guinea, Mali, and Sri Lanka were included on the basis of recent or retrospective testing of specimens collected during surveillance activities or studies. The abundance of asymptomatic and mild infections and limited diagnostic testing suggest that transmission in many locations likely remains underrecognized. Public health authorities, clinicians, communities at risk, and travelers should remain alert to the possibility of ZIKV transmission and implement measures to limit the risk of infection with ZIKV and other Aedes-borne arboviruses. To strengthen surveillance for ZIKV infections and congenital disease, targeted surveillance using clear case definitions and epidemiologically appropriate laboratory testing algorithms should be applied.

Understanding the Effect of a Changing Climate on the Re-Emergence of Mosquito-Borne Diseases in Vulnerable Small Island Nations: A Systematic Review

INTRODUCTION

Drastic changes in meteorological variables due to climate change will likely have an implication on the proliferation of vectors such as mosquitoes. Extreme weather events may therefore promote the emergence/re-emergence of mosquito-borne diseases (MBDs) and potentiate the risk of endemicity, particularly, in small island nations.

METHOD

A systematic review was chosen to methodically ascertain the knowledge gaps that exist in determining the influence of the changing climate on MBDs in small islands with vulnerable public health systems. This review was conducted using the PRISMA guidelines.

RESULTS

Following extraction of 600 articles from the databases, 16 studies were determined to meet the selection criteria. The majority of these research papers were from Sri Lanka (n = 9) while the remaining articles were distributed between islands in the Pacific and Atlantic Ocean. Several of these studies used regression modelling techniques to discuss the effect of multiple meteorological variables on the incidence of MBDs. A positive relationship was observed between temperature and the relative risk of MBDs in 72% of the papers. Rainfall enhanced dengue transmission in 84% of the studies included. All the articles discussing the effect of humidity illustrated a similar trend while wind speed was the only climatic variable demonstrating a negative relationship with MBDs.

DISCUSSION

Considering the intricate nature of the non-linear exposure-response link is crucial when estimating the lagged effect of the changing climate on MBDs transmission. Other challenges associated with bias and confounders in the selected studies as well as meteorological data accessibility, were highlighted. Therefore, it was not possible to conclusively establish that the changing climatic variables do influence the spread of MBDs which accentuated the need for conducting further studies to illustrate the effect of changing weather variables on the incidence of MBDs, with an emphasis on vulnerable small island nations.

Integrated serological surveillance for neglected tropical diseases, vaccine-preventable diseases, and arboviruses in Samoa, 2018

Multiplex bead immunoassays (MBA) can detect antibody responses to multiple antigens. Using MBA data from the Surveillance and Monitoring to Eliminate Lymphatic Filariasis (LF) and Scabies from Samoa (SaMELFS) 2018, we aim to estimate national seroprevalence of neglected tropical diseases (NTDs), vaccine-preventable diseases (VPDs), and arboviruses in Samoa. A community-based serosurvey of 3851 participants aged ≥ 5 years in 35 primary sampling units (PSUs). Using MBA, dried blood spots were assayed for antibodies (Ab) from 10 pathogens: LF, trachoma, yaws, tetanus, diphtheria, rubella, measles, dengue, Zika, and chikungunya. Seroprevalence was adjusted for study design, age, and gender. NTD seroprevalence for LF was 50.8% (Bm33 Ab), 32.0% (Wb123 Ab), 20.3% (Bm14 Ab); 5.5% for trachoma; and 1.0% (Tmpa Ab) and 0.2% (Rp17 Ab) for yaws. VPD seroprevalence was 91.0% for tetanus, 83.5% for diphtheria, 79.0% for rubella, and 43.6% for measles. Arbovirus seroprevalence for dengue was 91.1% (dengue virus serotype-1 [DENV-1]), 97.2% (DENV-2), 96.9% (DENV-3), 94.7% (DENV-4); 85.7% for Zika; and 57.0% for chikungunya. Increasing age was associated with seropositivity to NTDs, arboviruses, tetanus, and measles. Clustering was highest at the household level; the strongest clustering was for DENV-3 (intraclass correlation coefficient [ICC]:0.32), Bm33 Ab (ICC:0.31), and Bm14 Ab (ICC:0.31). Integrated serosurveillance can provide a comprehensive picture of population-level immunity to multiple diseases. Our investigation into associations with seroprevalence can aid the development of evidence-based prevention, control, and elimination strategies.

The launch of the Pacific vector network: connecting Pacific Island Countries and areas to prevent and control vector-borne diseases

The Pacific Island Health Officers' Association, the World Health Organization, and the Pacific Community co-organized the launch of the Pacific Vector Network (PVN) to address challenges posed by mosquito-borne diseases, including dengue fever, Zika virus disease, chikungunya, malaria, and lymphatic filariasis. The PVN was created as a new initiative under the Pacific Public Health Surveillance Network (PPHSN). This launch was a critical step in the build-up to PVN as a full-service network of PPHSN in the coming years. The Pacific Island Countries and areas (PIC)-led network comprises vector management leadership, officers, and technical partners dedicated to supporting information-sharing to promote evidence-based collective action and innovation. The setup of a Technical Working Body to ensure governance and to steer forward the work of the network was a key deliverable. This manuscript describes the proceedings and discussions of PIC representatives and several regional partners at the inaugural PVN meeting held 5-7 June 2023 in Hawai'i, USA.

Seroprevalence, incidence estimates, and environmental risk factors for dengue, chikungunya, and Zika infection amongst children living in informal urban settlements in Indonesia and Fiji

BACKGROUND

The burden of Aedes aegypti-transmitted viruses such as dengue, chikungunya, and Zika are increasing globally, fueled by urbanization and climate change, with some of the highest current rates of transmission in Asia. Local factors in the built environment have the potential to exacerbate or mitigate transmission.

METHODS

In 24 informal urban settlements in Makassar, Indonesia and Suva, Fiji, we tested children under 5 years old for evidence of prior infection with dengue, chikungunya, and Zika viruses by IgG serology. We used a catalytic model using seroprevalence and mean age to estimate annual incidence of dengue in each country. We also conducted detailed questionnaires to evaluate environmental risk factors for a positive serology result. Dengue risk factors were evaluated for children by univariate and multivariable logistic regression accounting for settlement as a fixed effect. Trash and flooding were additionally evaluated as dengue risk factors at the settlement level by univariate linear regression.

RESULTS

In Fiji and Indonesia respectively, 46% and 33% of children under 5 years old were seropositive for dengue, 3% and 3% for chikungunya, and 9% and 2% for Zika. In Indonesia, children living in a household where trash is routinely collected and removed were significantly less likely to be dengue seropositive in both unadjusted and adjusted models [adjusted model: OR 0.3 (95% CI: 0.1-0.8)]. In Indonesia, settlements with a higher proportion of households reporting flooding also had lower dengue rates (slope = 0.44; p-value: <0.05).

CONCLUSIONS

Household trash collection and community flood management are important targets for interventions to mitigate the increasing risk of Aedes aegypti-transmitted viruses.

Seroprevalence, incidence estimates, and environmental risk factors for dengue, chikungunya, and Zika infection amongst children living in informal urban settlements in Indonesia and Fiji

Background

The burden of Aedes aegypti-transmitted viruses such as dengue, chikungunya, and Zika are increasing globally, fueled by urbanization and climate change, with some of the highest current rates of transmission in Asia. Local factors in the built environment have the potential to exacerbate or mitigate transmission.

Methods

In 24 informal urban settlements in Makassar, Indonesia and Suva, Fiji, we tested children under 5 years old for evidence of prior infection with dengue, chikungunya, and Zika viruses by IgG serology. We used a catalytic model using seroprevalence and mean age to estimate annual incidence of dengue in each country. We also conducted detailed questionnaires to evaluate environmental risk factors for a positive serology result. Dengue risk factors were evaluated for individual children by univariate and multivariable logistic regression accounting for settlement as a flxed effect. Trash and flooding were additionally evaluated as dengue risk factors at the settlement level by univariate linear regression.

Results

In Fiji and Indonesia respectively, 46% and 33% of children under 5 years old were seropositive for dengue, 3% and 3% for chikungunya, and 9% and 2% for Zika. In Indonesia, children living in a household where trash is routinely collected and removed were signiflcantly less likely to be dengue seropositive in both unadjusted and adjusted models [adjusted model: OR 0.3 (95% CI: 0.1-0.8)]. In Indonesia, settlements with a higher proportion of households reporting flooding also had lower dengue rates (slope = 0.44; p-value: <0.05).

Conclusions

Household trash collection and community flood management are important targets for interventions to mitigate the increasing risk of Aedes aegypti-transmitted viruses.

Building capacity for testing sterile insect technique against Aedes-borne diseases in the Pacific: a training workshop and launch of sterile insect technique trials against Aedes aegypti and arboviral diseases

BACKGROUND

Vector-borne diseases cause morbidity and mortality globally. However, some areas are more impacted than others, especially with climate change. Controlling vectors remains the primary means to prevent these diseases, but new, more effective tools are needed. The World Health Organization (WHO) prioritized evaluating novel control methods, such as sterile insect technique (SIT) for control of Aedes-borne diseases. In response, a multiagency partnership between the U.S. Centers for Disease Control and Prevention (CDC), the Special Programme for Research and Training in Tropical Diseases (TDR), WHO, and the International Atomic Energy Agency (IAEA) supported the operational implementation and evaluation of SIT against Aedes aegypti and arboviral diseases in the Pacific through a consortium of regional partners (PAC-SIT Consortium).

MAIN TEXT

A workshop was held from 2 to 6 May 2023, during which PAC-SIT country participants, researchers, and stakeholders in SIT, scientific advisory committee members, and organizational partners came together to review the principles and components of SIT, share experiences, visit field sites and the SIT facility, and officially launch the PAC-SIT project. Working in groups focused on entomology, epidemiology, and community engagement, participants addressed challenges, priorities, and needs for SIT implementation.

CONCLUSIONS

The PAC-SIT workshop brought together researchers and stakeholders engaged in evaluating SIT for arboviral diseases in the Pacific region and globally. This training workshop highlighted that many countries are actively engaged in building operational capacities and phased testing of SIT. The workshop identified a key need for robust larger-scale studies tied with epidemiological endpoints to provide evidence for the scalability and impact on mosquito-borne diseases.

Dengue Virus and Zika Virus Seroprevalence in the South Pacific Populations of the Cook Islands and Vanuatu

Arboviral diseases are serious threats to global health with increasing prevalence and potentially severe complications. Significant arthropod-borne viruses are the dengue viruses (DENV 1-4), the Zika virus (ZIKV), and the chikungunya virus (CHIKV). Among the areas most affected is the South Pacific Region (SPR). Here, arboviruses not only cause a high local burden of disease, but the region has also proven to contribute to their global spread. Outpatient serum samples collected between 08/2016 and 04/2017 on three islands of the island states of Vanuatu and the Cook Islands were tested for anti-DENV- and anti-ZIKV-specific antibodies (IgG) using enzyme-linked immunosorbent assays (ELISA). ELISA test results showed 89% of all test sera from the Cook Islands and 85% of the Vanuatu samples to be positive for anti-DENV-specific antibodies. Anti-ZIKV antibodies were identified in 66% and 52%, respectively, of the test populations. Statistically significant differences in standardized immunity levels were found only at the intranational level. Our results show that in both the Cook Islands and Vanuatu, residents were exposed to significant Flavivirus transmission. Compared to other seroprevalence studies, the marked difference between ZIKV immunity levels and previously published CHIKV seroprevalence rates in our study populations is surprising. We propose the timing of ZIKV and CHIKV emergence in relation to recurrent DENV outbreaks and the impact of seasonality as explanatory external factors for this observation. Our data add to the knowledge of arboviral epidemics in the SPR and contribute to a better understanding of virus spread, including external conditions with potential influence on outbreak dynamics. These data may support preventive and rapid response measures in the affected areas, travel-related risk assessment, and infection identification in locals and returning travelers.

Successful introgression of wMel Wolbachia into Aedes aegypti populations in Fiji, Vanuatu and Kiribati

Pacific Island countries have experienced periodic dengue, chikungunya and Zika outbreaks for decades. The prevention and control of these mosquito-borne diseases rely heavily on control of Aedes aegypti mosquitoes, which in most settings are the primary vector. Introgression of the intracellular bacterium Wolbachia pipientis (wMel strain) into Ae. aegypti populations reduces their vector competence and consequently lowers dengue incidence in the human population. Here we describe successful area-wide deployments of wMel-infected Ae. aegypti in Suva, Lautoka, Nadi (Fiji), Port Vila (Vanuatu) and South Tarawa (Kiribati). With community support, weekly releases of wMel-infected Ae. aegypti mosquitoes for between 2 to 5 months resulted in wMel introgression in nearly all locations. Long term monitoring confirmed a high, self-sustaining prevalence of wMel infecting mosquitoes in almost all deployment areas. Measurement of public health outcomes were disrupted by the Covid19 pandemic but are expected to emerge in the coming years.

Clinical manifestations of dengue, Zika and chikungunya in the Pacific Islands: A systematic review and meta-analysis

Dengue, Zika and chikungunya outbreaks pose a significant public health risk to Pacific Island communities. Differential diagnosis is challenging due to overlapping clinical features and limited availability of laboratory diagnostic facilities. There is also insufficient information regarding the complications of these arboviruses, particularly for Zika and chikungunya. We conducted a systematic review and meta-analysis to calculate pooled prevalence estimates with 95% confidence intervals (CI) for the clinical manifestations of dengue, Zika and chikungunya in the Pacific Islands. Based on pooled prevalence estimates, clinical features that may help to differentiate between the arboviruses include headache, haemorrhage and hepatomegaly in dengue; rash, conjunctivitis and peripheral oedema in Zika; and the combination of fever and arthralgia in chikungunya infections. We estimated that the hospitalisation and mortality rates in dengue were 9.90% (95% CI 7.67-12.37) and 0.23% (95% CI 0.16-0.31), respectively. Severe forms of dengue occurred in 1.92% (95% CI 0.72-3.63) of reported cases and 23.23% (95% CI 13.58-34.53) of hospitalised patients. Complications associated with Zika virus included Guillain-Barré syndrome (GBS), estimated to occur in 14.08 (95% CI 11.71-16.66) per 10,000 reported cases, and congenital brain malformations such as microcephaly, particularly with first trimester maternal infection. For chikungunya, the hospitalisation rate was 2.57% (95% CI 1.30-4.25) and the risk of GBS was estimated at 1.70 (95% CI 1.06-2.48) per 10,000 reported cases. Whilst ongoing research is required, this systematic review enhances existing knowledge on the clinical manifestations of dengue, Zika and chikungunya infections and will assist Pacific Island clinicians during future arbovirus outbreaks.

Temperature and transmission of chikungunya, dengue, and Zika viruses: A systematic review of experimental studies on Aedes aegypti and Aedes albopictus

Mosquito-borne viruses are leading causes of morbidity and mortality in many parts of the world. In recent years, modelling studies have shown that climate change strongly influences vector-borne disease transmission, particularly rising temperatures. As a result, the risk of epidemics has increased, posing a significant public health risk. This review aims to summarize all published laboratory experimental studies carried out over the years to determine the impact of temperature on the transmission of arboviruses by the mosquito vector. Given their high public health importance, we focus on dengue, chikungunya, and Zika viruses, which are transmitted by the mosquitoes Aedes aegypti and Aedes albopictus. Following PRISMA guidelines, 34 papers were included in this systematic review. Most studies found that increasing temperatures result in higher rates of infection, dissemination, and transmission of these viruses in mosquitoes, although several studies had differing findings. Overall, the studies reviewed here suggest that rising temperatures due to climate change would alter the vector competence of mosquitoes to increase epidemic risk, but that some critical research gaps remain.

Arboviral disease outbreaks, Aedes mosquitoes, and vector control efforts in the Pacific

Recurring outbreaks of mosquito-borne diseases, like dengue, in the Pacific region represent a major biosecurity risk to neighboring continents through potential introductions of disease-causing pathogens. Aedes mosquitoes, highly prevalent in this region, are extremely invasive and the predominant vectors of multiple viruses including causing dengue, chikungunya, and Zika. Due to the absence of vaccines for most of these diseases, Aedes control remains a high priority for public health. Currently, international organizations put their efforts into improving mosquito surveillance programs in the Pacific region. Also, a novel biocontrol method using Wolbachia has been tried in the Pacific region to control Aedes mosquito populations. A comprehensive understanding of mosquito biology is needed to assess the risk that mosquitoes might be introduced to neighboring islands in the region and how this might impact arboviral virus transmission. As such, we present a comprehensive review of arboviral disease outbreak records as well as Aedes mosquito biology research findings relevant to the Pacific region collected from both non-scientific and scientific sources.

Chikungunya virus (CHIKV) seroprevalence in the South Pacific populations of the Cook Islands and Vanuatu with associated environmental and social factors

BACKGROUND

Arthropod-borne diseases pose a significant and increasing risk to global health. Given its rapid dissemination, causing large-scale outbreaks with severe human infections and economic loss, the Chikungunya virus (CHIKV) is one of the most important arboviruses worldwide. Despite its significance, the real global impact of CHIKV remains underestimated as outbreak data are often incomplete and based solely on syndromic surveillance. During 2011-2016, the South Pacific Region was severely affected by several CHIKV-epidemics, yet the area is still underrepresented in arboviral research.

METHODS

465 outpatient serum samples collected between 08/2016 and 04/2017 on three islands of the island states Vanuatu (Espiritu Santo) and the Cook Islands (Rarotonga, Aitutaki) were tested for anti-CHIKV specific antibodies using Enzyme-linked immunosorbent Assays.

RESULTS

A total of 30% (Cook Islands) and 8% (Vanuatu) of specimens were found positive for anti-CHIKV specific antibodies with major variations in national and intranational immunity levels. Seroprevalence throughout all age groups was relatively constant. Four potential outbreak-protective factors were identified by comparing the different study settings: presence of Ae. albopictus (in absence of ECSA E1-A226V-mutation CHIKV), as well as low levels of human population densities, residents' travel activity and tourism.

CONCLUSION

This is the first seroprevalence study focussing on an arboviral disease in the Cook Islands and Vanuatu. It highlights the impact of the 2014/2015 CHIKV epidemic on the Cook Islands population and shows that a notable part of the Vanuatu test population was exposed to CHIKV although no outbreaks were reported. Our findings supplement the knowledge concerning CHIKV epidemics in the South Pacific Region and contribute to a better understanding of virus dissemination, including outbreak modifying factors. This study may support preventive and rapid response measures in affected areas, travel-related risk assessment and infection identification in returning travellers.

TRIAL REGISTRATION

ClinicalTrials.gov Aachen: 051/16_09/05/2016 Cook Islands Ref.: #16-16 Vanuatu Ref.: MOH/DG 10/1/1-GKT/lr.