Mechanisms of Yellow Fever Transmission: Gleaning the Overlooked Records of Importance and Identifying Problems, Puzzles, Serious Issues, Surprises and Research Questions

In viral disease research, few diseases can compete with yellow fever for the volume of literature, historical significance, richness of the topics and the amount of strong interest among both scientists and laypersons. While the major foci of viral disease research shifted to other more pressing new diseases in recent decades, many critically important basic tasks still remain unfinished for yellow fever. Some of the examples include the mechanisms of transmission, the process leading to outbreak occurrence, environmental factors, dispersal, and viral persistence in nature. In this review, these subjects are analyzed in depth, based on information not only in old but in modern literatures, to fill in blanks and to update the current understanding on these topics. As a result, many valuable facts, ideas, and other types of information that complement the present knowledge were discovered. Very serious questions about the validity of the arbovirus concept and some research practices were also identified. The characteristics of YFV and its pattern of transmission that make this virus unique among viruses transmitted by Ae. aegypti were also explored. Another emphasis was identification of research questions. The discovery of a few historical surprises was an unexpected benefit.

Widespread Interspecific Phylogenetic Tree Incongruence Between Mosquito-Borne and Insect-Specific Flaviviruses at Hotspots Originally Identified in Zika Virus

Intraspecies (homologous) phylogenetic incongruence, or ‘tree conflict’ between different loci within the same genome of mosquito-borne flaviviruses (MBFV), was first identified in dengue virus (DENV) and subsequently in Japanese encephalitis virus (JEV), St Louis encephalitis virus, and Zika virus (ZIKV). Recently, the first evidence of phylogenetic incongruence between interspecific members of the MBFV was reported in ZIKV and its close relative, Spondweni virus. Uniquely, these hybrid proteomes were derived from four incongruent trees involving an Aedes-associated DENV node (1 tree) and three different Culex-associated flavivirus nodes (3 trees). This analysis has now been extended across a wider spectrum of viruses within the MBFV lineage targeting the breakpoints between phylogenetic incongruent loci originally identified in ZIKV. Interspecies phylogenetic incongruence at these breakpoints was identified in 10 of 50 viruses within the MBFV lineage, representing emergent Aedes and Culex-associated viruses including JEV, West Nile virus, yellow fever virus, and insect-specific viruses. Thus, interspecies phylogenetic incongruence is widespread amongst the flaviviruses and is robustly associated with the specific breakpoints that coincide with the interspecific phylogenetic incongruence previously identified, inferring they are ‘hotspots’. The incongruence amongst the emergent MBFV group was restricted to viruses within their respective associated epidemiological boundaries. This MBFV group was RY-coded at the third codon position (‘wobble codon’) to remove transition saturation. The resulting ‘wobble codon’ trees presented a single topology for the entire genome that lacked any robust evidence of phylogenetic incongruence between loci. Phylogenetic interspecific incongruence was therefore observed for exactly the same loci between amino acid and the RY-coded ‘wobble codon’ alignments and this incongruence represented either a major part, or the entire genomes. Maximum likelihood codon analysis revealed positive selection for the incongruent lineages. Positive selection could result in the same locus producing two opposing trees. These analyses for the clinically important MBFV suggest that robust interspecific phylogenetic incongruence resulted from amino acid selection. Convergent or parallel evolutions are evolutionary processes that would explain the observation, whilst interspecific recombination is unlikely.

The Absence of Yellow Fever in Asia: History, Hypotheses, Vector Dispersal, Possibility of YF in Asia, and Other Enigmas

Since the recent epidemics of yellow fever in Angola and Brazil as well as the importation of cases to China in 2016, there has been an increased interest in the century-old enigma, absence of yellow fever in Asia. Although this topic has been repeatedly reviewed before, the history of human intervention has never been considered a critical factor. A two-stage literature search online for this review, however, yielded a rich history indispensable for the debate over this medical enigma. As we combat the pandemic of COVID-19 coronavirus worldwide today, we can learn invaluable lessons from the historical events in Asia. In this review, I explore the history first and then critically examine in depth major hypotheses proposed in light of accumulated data, global dispersal of the principal vector, patterns of YF transmission, persistence of urban transmission, and the possibility of YF in Asia. Through this process of re-examination of the current knowledge, the subjects for research that should be conducted are identified. This review also reveals the importance of holistic approach incorporating ecological and human factors for many unresolved subjects, such as the enigma of YF absence in Asia, vector competence, vector dispersal, spillback, viral persistence and transmission mechanisms.

Recombination of B- and T-cell epitope-rich loci from Aedes- and Culex-borne flaviviruses shapes Zika virus epidemiology

Sporadic human Zika virus (ZIKV) infections have been recorded in Africa and Asia since the 1950s. Major epidemics occurred only after ZIKV emerged in the Pacific islands and spread to the Americas. Specific biological determinants of the explosive epidemic nature of ZIKV have not been identified. Phylogenetic studies revealed incongruence in ZIKV placement in relation to Aedes-borne dengue viruses (DENV) and Culex-borne flaviviruses. We hypothesized that this incongruence reflects interspecies recombination resulting in ZIKV evasion of cross-protective T-cell immunity. We investigated ZIKV phylogenetic incongruence in relation to: DENV T-cell epitope maps experimentally identified ex vivo, published B-cell epitope loci, and CD8⁺ T-cell epitopes predicted in silico for mosquito-borne flaviviruses. Our findings demonstrate that the ZIKV proteome is a hybrid of Aedes-borne DENV proteins interspersed amongst Culex-borne flavivirus proteins derived through independent interspecies recombination events. These analyses infer that DENV-associated proteins in the ZIKV hybrid proteome generated immunodominant human B-cell responses, whereas ZIKV recombinant derived Culex-borne flavivirus-associated proteins generated immunodominant CD8⁺ and/or CD4⁺ T-cell responses. In silico CD8⁺ T-cell epitope ZIKV cross-reactive prediction analyses verified this observation. We propose that by acquiring cytotoxic T-cell epitope-rich regions from Culex-borne flaviviruses, ZIKV evaded DENV-generated T-cell immune cross-protection. Thus, Culex-borne flaviviruses, including West Nile virus and Japanese encephalitis virus, might induce cross-protective T-cell responses against ZIKV. This would explain why explosive ZIKV epidemics occurred in DENV-endemic regions of Micronesia, Polynesia and the Americas where Culex-borne flavivirus outbreaks are infrequent and why ZIKV did not cause major epidemics in Asia where Culex-borne flaviviruses are widespread.

Vertebrate Reservoirs of Arboviruses: Myth, Synonym of Amplifier, or Reality?

The rapid succession of the pandemic of arbovirus diseases, such as dengue, West Nile fever, chikungunya, and Zika fever, has intensified research on these and other arbovirus diseases worldwide. Investigating the unique mode of vector-borne transmission requires a clear understanding of the roles of vertebrates. One major obstacle to this understanding is the ambiguity of the arbovirus definition originally established by the World Health Organization. The paucity of pertinent information on arbovirus transmission at the time contributed to the notion that vertebrates played the role of reservoir in the arbovirus transmission cycle. Because this notion is a salient feature of the arbovirus definition, it is important to reexamine its validity. This review addresses controversial issues concerning vertebrate reservoirs and their role in arbovirus persistence in nature, examines the genesis of the problem from a historical perspective, discusses various unresolved issues from multiple points of view, assesses the present status of the notion in light of current knowledge, and provides options for a solution to resolve the issue.

A Re-Examination of the History of Etiologic Confusion between Dengue and Chikungunya

Contrary to the perception of many researchers that the recent invasion of chikungunya (CHIK) in the Western Hemisphere marked the first episode in history, a recent publication reminded them that CHIK had prevailed in the West Indies and southern regions of the United States from 1827-1828 under the guise of "dengue" (DEN), and that many old outbreaks of so-called "dengue" actually represented the CHIK cases erroneously identified as "dengue." In hindsight, this confusion was unavoidable, given that the syndromes of the two diseases-transmitted by the same mosquito vector in urban areas-are very similar, and that specific laboratory-based diagnostic techniques for these diseases did not exist prior to 1940. While past reviewers reclassified problematic "dengue" outbreaks as CHIK, primarily based on manifestation of arthralgia as a marker of CHIK, they neither identified the root cause of the alleged misdiagnosis nor did they elaborate on the negative consequences derived from it. This article presents a reconstructed history of the genesis of the clinical definition of dengue by emphasizing problems with the definition, subsequent confusion with CHIK, and the ways in which physicians dealt with the variation in dengue-like ("dengue") syndromes. Then, the article identifies in those records several factors complicating reclassification, based on current practice and standards. These factors include terms used for characterizing joint problems, style of documenting outbreak data, frequency of manifestation of arthralgia, possible involvement of more than one agent, and occurrence of the principal vector. The analysis of those factors reveals that while some of the old "dengue" outbreaks, including the 1827-1828 outbreaks in the Americas, are compatible with CHIK, similar reclassification of other "dengue" outbreaks to CHIK is difficult because of a combination of the absence of pathognomonic syndrome in these diseases and conflicting background information.

Genetic divergence among members of the Kokobera group of flaviviruses supports their separation into distinct species

The Kokobera virus group comprises mosquito-borne flaviviruses that cluster together phylogenetically. These viruses are unique to Australia and Papua New Guinea, and have been associated with a mild polyarticular disease in humans. Recent isolation of genetically diverse viruses within this group has prompted analysis of their genetic and phenotypic relationships. Phylogenetic analysis based on complete ORF, the envelope gene or the NS5/3' untranslated region supported the separation of the group into distinct species: Kokobera virus (KOKV), Stratford virus, New Mapoon virus, MK7979 and TS5273. Virulence studies in 3-week-old mice also provided the first evidence that a member of the KOKV group (MK7979) was neuroinvasive after intraperitoneal inoculation. In this context, our recent detection of KOKV group-specific antibodies in horses in the field suggests that these viruses should be considered in the epidemiology of flavivirus encephalitis in Australia.

Revisiting Houston and Memphis: the background histories behind the discovery of the infestation by Aedes albopictus (Diptera: Culicidae) in the United States and their significance in the contemporary research

The discovery of Aedes albopictus Skuse infestation in Texas in 1985 and subsequent global spread of this mosquito have spawned a large number of publications worldwide. The unique discovery in this episode was used tire trade as mechanism by which this exotic mosquito was introduced to the United States. While most researchers have focused their attention primarily on recent events and scientific progress, far fewer examined in depth early contributions made in the United States still very much relevant for contemporary discussion and other important subjects associated with its infestation. The first part of this review covers early background histories of research on Ae. albopictus in the institutions in the United States and of introduction of Ae. albopictus and Ae. aegypti to the U.S. territories in the eastern Pacific as well as dengue outbreaks therein. The second part covers evolution of recognition of the importance of tire as breeding site of domesticated or peridomestic dengue vectors and of its transport in the dispersal of these mosquitoes. In the third part, the significance of vector-borne viral disease outbreak potential of Ae. albopictus and Ae. aegypti in temperate regions and a variety of problems concerning vector spread and commercial practices learned in the past are reassessed in the context of contemporary research. I further identified as byproducts of this review two potentially important epidemiological mechanisms in the transmission of dengue in temperate regions, increasing tendency of indoor activity of Ae. albopictus and massive human movement associated with unpredictable political development.

Early history of laboratory breeding of Aedes aegypti (Diptera: Culicidae) focusing on the origins and use of selected strains

The yellow fever mosquito, Aedes aegypti (L.) (Diptera: Culicidae), is well recognized for its extensive adaptation to diverse ecological conditions and for genetic variation. Recognizing the importance of strain variation of this mosquito, researchers have established a large number of laboratory strains. Some of the popular strains have been used for research for years in many laboratories around the world. However, the exact origins of many of these strains are unknown. In this review, publications and archival records were examined to report the early laboratory mosquito rearing practices around the world and to identify the origins of selected strains. The records showed that inter-laboratory sharing of strains was already underway in the early part of the 20th century because of the ease of breeding Ae. aegypti and of sending eggs by mail. It also was found that the four strains established in major U.S. institutions by the mid-1930s, including the "ROCK" (short for Rockefeller) strain, had been derived from Cuba, Nigeria, Philippines, or Puerto Rico, all known for a long history of transmission of yellow fever virus or dengue virus rather than from North America. The strains used for research in Europe were primarily derived from West Africa, but strains of Asian, Caribbean, and South American origins also were used for comparative experiments among geographic strains. Neglected issues related to strain designation and original source identification in scientific publications were found and their relevance to current research is discussed.

Research on dengue and dengue-like illness in East Asia and the Western Pacific during the First Half of the 20th century

Dengue has become an enormous medical problem worldwide since the end of the World War II (WWII). Despite a voluminous amount of research conducted worldwide for many years to elucidate the mechanism of the development of the two severe forms of dengue (dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS)), to develop effective vaccines and to design reliable disease control and prevention strategies, the goals of achieving these objectives are not in sight yet. For such a medical research that requires a multi-directional approach to resolve a variety of research questions, sometimes it is necessary to step back and re-examine historically how the current status of the expanding global problems and sudden emergence of severe forms of dengue have evolved in the first place. To examine the history of dengue epidemiology, it is first necessary to put in perspective all relevant documents, including a large number of nearly forgotten, old Japanese publications regarding dengue outbreaks and allied background information in East Asia and the Western Pacific that were documented before the emergence of the haemorrhagic disease outbreaks in the 1950s there. The compiled data in this review, thus, fill in for the first time many blanks in the early epidemiologic history of dengue in this part of the world. Besides the data for epidemiologists, virologic data, clinical studies of haemorrhagic manifestation, significance in military medicine and entomologic investigations covered in this review should be useful for the current researchers investigating any of those subjects.

Complete genome characterization of Rocio virus (Flavivirus: Flaviviridae), a Brazilian flavivirus isolated from a fatal case of encephalitis during an epidemic in São Paulo state

The flaviviruses of major medical importance in South American countries are yellow fever, dengue, Saint Louis encephalitis, West Nile and Rocio viruses. Rocio virus (ROCV) has been responsible for epidemics of severe encephalitis in Brazil with a case-fatality rate of 10 % and development of sequelae in 20 % of the survivors. We have sequenced and characterized the entire genome of ROCV for the first time, by determining the general traits of the open reading frame and the characteristics of viral genes including the potential cleavage sites, conserved or unique motifs, cysteine residues and potential glycosylation sites. The conserved sequences in the 3′-non-coding region were identified, and the predicted secondary structures during cyclization between 5′- and 3′-non-coding regions were studied. Multiple protein and phylogenetic analyses based on antigenically important and phylogenetically informative genes confirmed a close relationship between ROCV and Ilheus virus (ILHV), together constituting a unique and distinct phylogenetic subgroup as well as the genetic relationship of ROCV with several members of the Japanese encephalitis group. Although ROCV is phylogenetically related to ILHV, our study shows that it is still a virus distinct from the latter virus. This is the first flavivirus uniquely indigenous to Brazil that has been sequenced completely and the genome characterized. The data should be useful for further studies at the molecular level, including construction of infectious clone, identification of gene function, improved disease surveillance based on molecular diagnostic tools and vaccine development.

Full-length sequencing and genomic characterization of Bagaza, Kedougou, and Zika viruses

Many members of the genus Flavivirus are the agents of important diseases of humans, livestock, and wildlife. Currently, no complete genome sequence is available for the three African viruses, Bagaza, Zika, and Kedougou viruses, each representing a distinct virus subgroup according to the latest virus classification. In this study, we obtained a complete genome sequence of each of those three viruses and characterized the open reading frames (ORFs) with respect to gene sizes, cleavage sites, potential glycosylation sites, distribution of cysteine residues, and unique motifs. The sequences of the three viruses were then scanned across the entire length of the ORF against available sequences of other African flaviviruses and selected reference viruses for genetic relatedness. The data collectively indicated that Kedougou virus was close to dengue viruses but nonetheless distinct, while Bagaza virus shared genetic relatedness with West Nile virus in several genomic regions. In the non-coding regions, it was found that a particular organizational pattern of conserved sequences in the 3' terminal region generally correlated with the current virus grouping.

Host range specificity of flaviviruses: correlation with in vitro replication

Vector-borne flaviviruses have been traditionally grouped into either mosquito-borne or tick-borne group. However, this vector range specificity has sometimes been questioned because of the puzzling records of occasional isolation of mosquito-borne viruses from ticks and of tick-borne viruses from mosquitoes. In this study, host range of the flaviviruses representing not only the two vector-borne groups but also insect flaviviruses and vertebrate viruses that are not arboviruses was comprehensively reexamined by a serial passage experiment in vitro by using cell cultures derived from mosquitoes, ticks, and vertebrates. The results showed that the host range specificity in the four groups of viruses, based on replication for five consecutive passages as a criterion to evaluate the ability of viruses to replicate in three different cell cultures, agreed with the conventional grouping as well as phylogenetic clustering. Thus, this assay provides useful, supplementary information regarding host range for those flaviviruses when their natural host range is unknown, ambiguous, or questionable.

Characterization of Sepik and Entebbe bat viruses closely related to yellow fever virus

Yellow fever virus has a special place in medical history as the first animal virus isolated and as the prototype virus in the genus Flavivirus, which contains many serious human pathogens. Only recently, its closely related viruses within the group were identified phylogenetically. In this study, we obtained complete or near complete genome sequences of two viruses most closely related to yellow fever virus: Sepik virus of Papua New Guinea and Entebbe bat virus of Africa. Based on full-genomic characterization and genomic traits among related viruses, we identified Sepik virus to be most closely related to yellow fever virus and analyzed the pattern of repeat and conserved sequence motifs in the 3'-noncoding region among the members of yellow fever virus cluster. We also discuss the geographic dispersal as a part of ecological traits of this lineage of flaviviruses.

Biological transmission of arboviruses: reexamination of and new insights into components, mechanisms, and unique traits as well as their evolutionary trends

Among animal viruses, arboviruses are unique in that they depend on arthropod vectors for transmission. Field research and laboratory investigations related to the three components of this unique mode of transmission, virus, vector, and vertebrate host, have produced an enormous amount of valuable information that may be found in numerous publications. However, despite many reviews on specific viruses, diseases, or interests, a systematic approach to organizing the available information on all facets of biological transmission and then to interpret it in the context of the evolutionary process has not been attempted before. Such an attempt in this review clearly demonstrates tremendous progress made worldwide to characterize the viruses, to comprehend disease transmission and pathogenesis, and to understand the biology of vectors and their role in transmission. The rapid progress in molecular biologic techniques also helped resolve many virologic puzzles and yielded highly valuable data hitherto unavailable, such as characterization of virus receptors, the genetic basis of vertebrate resistance to viral infection, and phylogenetic evidence of the history of host range shifts in arboviruses. However, glaring gaps in knowledge of many critical subjects, such as the mechanism of viral persistence and the existence of vertebrate reservoirs, are still evident. Furthermore, with the accumulated data, new questions were raised, such as evolutionary directions of virus virulence and of host range. Although many fundamental questions on the evolution of this unique mode of transmission remained unresolved in the absence of a fossil record, available observations for arboviruses and the information derived from studies in other fields of the biological sciences suggested convergent evolution as a plausible process. Overall, discussion of the diverse range of theories proposed and observations made by many investigators was found to be highly valuable for sorting out the possible mechanism(s) of the emergence of arboviral diseases.

Identification of new flaviviruses in the Kokobera virus complex

Novel flavivirus isolates from mosquitoes collected in northern Australia were analysed by partial genomic sequencing, monoclonal antibody-binding assays and polyclonal cross-neutralization tests. Two isolates were found to be antigenically distinct from, but related to, viruses of the Kokobera virus complex, which currently contains Kokobera (KOKV) and Stratford (STRV) viruses. Nucleotide sequence comparison of two separate regions of the genome revealed that an isolate from Saibai Island in the Torres Strait in 2000 (TS5273) was related closely to KOKV and STRV, with 74–80 and 75–76 % nucleotide similarity, respectively. An isolate from mainland Cape York in 1998 (CY1014) was found to be more divergent from KOKV and STRV, with <70 % nucleotide sequence similarity to either virus. It is proposed that isolate TS5273 represents a new subtype of KOKV and that CY1014 be classified as a novel species within the Kokobera virus complex of flaviviruses, named New Mapoon virus.

Recent advancement in flavivirus vaccine development

Lately, the magnitude of cumulative diseases burden caused by flaviviruses, such as dengue virus, Japanese encephalitis virus, tick-borne encephalitis virus, West Nile virus and yellow fever virus, has reached an unprecedented level with the sizes of human and animal populations at risk increasing sharply. These diseases present highly complex medical, economic and ecologic problems, some effecting primarily human and others affecting human, livestock and wildlife. The large body of recent publications on the development of vaccines taking advantage of new generations of bio-engineering techniques clearly reflects the profound interests and deep sense of urgency in the scientific and medical communities in combating those diseases. This review reveals a collection of remarkable progresses thus far made in flaviviral vaccine research not only employing a diverse range of new strategies but also re-tooling old techniques to improve the existing vaccines. The efficacy and safety of some of the new vaccine candidates have been evaluated and proven in human clinical trials. Besides the technical advancement in vaccine development, in this review, the importance of somewhat neglected and yet critical subjects, such as adequacy of animal model, vaccine safety, vaccine formulation and delivery, complication in serodiagostics and economic factor, was examined in-depth.

A survey of the relationships among the viruses not considered arboviruses, vertebrates, and arthropods

No single group of organisms demonstrates more extensive and diverse associations with animal viruses than the phylum Arthropoda. Compared with the well-recognized relationship found in arboviruses, however, most of the atypical arthropod-vertebrate relationships of the viruses normally not considered arboviruses have received much less attention, as they remain in the marginal areas of interest for most researchers in animal virology, veterinary medicine, medical entomology, and invertebrate pathology. However, this comprehensive review of the information gathered from several branches of virology by profession reveals highly valuable information potentially useful in the fields of research ranging from investigations of the mode of transmission of poorly understood or emerging viral diseases to studies of the evolution of biological transmission of animal viruses by arthropod vectors. The observations and data obtained for the animal virus relationships with arthropods and vertebrates outside the boundaries of arboviruses, in turn, can be used to reexamine more closely the definition of arboviruses. With increasing number of reports challenging one of the basic tenets of the definition of arbovirus (requirement of viremia in vertebrate host) and others describing virus-host relationships that complicate the definition of arbovirus, the accumulated information clearly demonstrates the difficulty of defining the boundaries of arboviruses.

Phylogeny of Thogoto virus

Thogoto virus is a tick-borne member of the family Orthomyxoviridae. Previously, based on the similarity in antigenic relationship by cross-neutralization test, all virus strains were concluded to have derived from the same origin. In this study, we obtained partial gene sequences of 4 genes (PB1-like protein, PA-like protein, glycoprotein, and nucleoprotein) of 8 Thogoto virus strains isolated in Africa, Asia, and Europe and studied the genetic variation and phylogeny. Unrooted phylogenetic trees created by both neighbor-joining and maximum likelihood methods based on nucleotide and amino acid sequences for 4 genes were mostly similar and revealed two lineages, Euro-Asian and African. Intra-lineage nucleotide sequence variation was greater in the Euro-Asian lineage than in the African lineage for all 4 genes. Furthermore, for the strains of Euro-Asian lineage, variations for two genes associated with RNA-dependent RNA polymerase activities were greater than those for glycoprotein or nucleoprotein gene, based on both nucleotide and amino acid sequence differences as well as on synonymous and nonsynonymous differences, indicating greater mutation rates for the polymerase activity genes in these strains.

Flavivirus DNA vaccines: current status and potential

The use of DNA-based vaccines is a novel and promising immunization approach for the development of flavivirus vaccines. This approach has been attempted in vaccine development for various virus species, including St. Louis encephalitis, Russian spring-summer encephalitis, Central European encephalitis, dengue serotypes 1 and 2, Murray Valley encephalitis, Japanese encephalitis, and West Nile viruses. However, very little is known about the factors affecting its efficacy. Recently, we demonstrated that a single intramuscular immunization of DNA vaccine of Japanese encephalitis and West Nile viruses protected mice and horses from virus challenge. Administration of these recombinant plasmid vectors resulted in endogenous expression and secretion of extracellular virus-like particles that correlated well with the induction of protective immunity. These results provided evidence that the virus-like particles composed of premembrane/membrane and envelope proteins are essential for eliciting immune responses similar to those induced by live, attenuated virus vaccines. The biosynthesis and protein processing of premembrane/membrane and envelope proteins that preserve the native conformation and glycosylation profiles identical to virion proteins could be determined by the effectiveness of the transmembrane signal sequence located at the amino-terminus of premembrane protein. The use of DNA vaccines in multivalent and/or combination vaccines designed to immunize against multiple flaviviruses is also a promising area of development.

Genomic sequencing of deer tick virus and phylogeny of powassan-related viruses of North America

Powassan (POW) virus is responsible for central nervous system infection in humans in North America and the eastern parts of Russia. Recently, a new flavivirus, deer tick (DT) virus, related to POW virus was isolated in the United States, but neither its pathogenic potential in human nor the taxonomic relationship with POW virus has been elucidated. In this study, we obtained the near-full-length genomic sequence of the DT virus and complete sequences of 3 genomic regions of 15 strains of POW-related virus strains. The phylogeny revealed 2 lineages, one of which had the prototype POW virus and the other DT virus. Both lineages can cause central nervous system infection in humans. By use of the combination of molecular definition of virus species within the genus Flavivirus and serological distinction in a 2-way cross-neutralization test, the lineage of DT virus is classified as a distinct genotype of POW virus.

Persistence of arboviruses and antiviral antibodies in vertebrate hosts: its occurrence and impacts

The recent isolation of West Nile virus from a bird in mid-winter in New York immediately raised, as one of a few explanations, the possibility of long-term persistence of arboviruses in vertebrate hosts. Although it was a highly popular topic for research many years ago, generally it has since been neglected and its meaning under appreciated. This comprehensive survey of literature worldwide uncovered, contrary to the general perception that it is a rather infrequent phenomenon, a large number of important observations involving all groups of arboviruses that have been accumulating over the years without drawing much attention. In this review, the data and observations were analysed in terms of the occurrence, role in natural transmission, mechanisms and genesis of persistence, source of problems in research and impact. The outcome of the analyses clearly demonstrates that asymptomatic, long-term infection in the absence of viraemia with or without the induction of neutralising antibody, the most frequent characteristics of arboviral persistence, presents a serious question about the validity of some of the past animal experiments that were conducted without the consideration of such a possibility. Likewise, significant impacts are felt on diverse fields ranging from epidemiology to diagnostic virology and from veterinary medicine to agricultural commerce. Published in 2001 by John Wiley & Sons, Ltd.

Transmission of arboviruses without involvement of arthropod vectors

Transmission of arboviruses (arthropod-borne viruses belonging to various virus families) without involvement of arthropod vectors has been documented for years, but the reports have not been reviewed systematically. The recent report of West Nile (WN) virus isolation from a hawk in mid-winter in New York (Garmendia et al., J. Clin. Microbiol. 38, 3110-3111, 2000) generated a considerable interest in this mode of arbovirus transmission. In this article, the data available worldwide are analyzed according to the factors involved in such a transmission under natural conditions, mode of infection, virus entry mechanism, administration and efficacy evaluation of vaccines, and significance in agricultural trade and public health. Analysis of numerous reports compiled for this review revealed that peroral and intranasal/aerosol transmissions are very common among arboviruses. The mechanism of virus infections in animals was most extensively studied for intranasal/aerosol infection, confirming two routes of virus spread to central nervous system (CNS), olfactory and hematogenous. To rule out the possibility of asymptomatic, cryptic infection the efficacy evaluation of candidates for vaccines against neurotropic arboviruses should include virus isolation from tissues of not only symptomatic but also of asymptomatic animals that survive intranasal virus challenge. Human activities, such as feeding livestock animals with food containing virus-contaminated meat and assembling a large number of livestock from many geographically-separated locations, have been identified as a cause of spread of some arboviral diseases. Despite numerous laboratory reports, the significance of this mode of transmission of arboviruses under natural conditions was rarely investigated, except for a few viruses important for veterinary medicine.

Evaluation of an IgM immunoblot kit for dengue diagnosis

A commercial IgM immunoblot kit was evaluated for dengue diagnosis with a panel of serum specimens collected from patients in a dengue endemic area. The kit is not recommended for use in its present form because of its undesirable rate of false-positive results. However, by substituting internal controls with the reference positive and negative controls that are more representative of those seen in endemic areas and by modifying the positive and negative scoring criteria, sensitivity and specificity of 80.3% and 94.5%, respectively, were obtained. These results are comparable with those obtained with the IgM ELISA on specimens, most of which were obtained from outpatient health care facilities. With further technical modifications, inclusion of a visual guide to ensure scoring standardization, and a more complete elaboration of the limitations of the test, wide application of the kit in diagnostic laboratories should be possible.

Universal diagnostic RT-PCR protocol for arboviruses

A selected number of PCR protocols were evaluated to determine if they could serve as a universal protocol for detecting and identifying all arboviruses. In this study, four parameters that affect the efficacy of RT-PCR (RNA extraction method, choice of reverse transcriptase, choice of DNA polymerase and thermocycling program) were evaluated in combination. The most optimal combination of those parameters employed use of silica gel membrane spin column, RAV-2 reverse transcriptase, Tth DNA polymerase, and a simple modification of a published thermocycling program. By this modified protocol, viral RNA could be amplified satisfactorily with more than 50 pairs of primers designed for diagnosis of arboviruses representing five families. The sensitivity and specificity obtained by this universal protocol were comparable to those obtained by the original protocol for each primer pair tested; and for some primers, improved sensitivity was observed. It was also found that a simple modification of a suggested protocol of a commercial RT-PCR kit could produce nearly identical results and serve as another universal protocol. With the use of a universal diagnostic reverse transcriptase-polymerase chain reaction (RT-PCR) protocol, simultaneous screening of clinical or biological specimens against a large number of RNA viruses belonging to many families can be performed more efficiently for etiologic determination in the situations complicated by the difficulty of differential diagnosis. Furthermore, such a universal protocol facilitates reducing the cost of PCR-based diagnostic operation and standardizing the qualities of PCR-based diagnosis within an institution or among collaborating institutions. A logical strategy is to conduct diagnosis in two stages by using broadly group-reactive primers in the first stage to narrow the range of possible etiologic agents and using virus-specific primers in the second stage for identification. Before such a strategy is employed, however, more group-reactive primers for a large number of arboviruses, for which no such primers currently exist, must be made available. Furthermore, the best pair or pairs of primers need to be selected for each virus for the second stage of the strategy.

Phylogeny of the genus Flavivirus

We undertook a comprehensive phylogenetic study to establish the genetic relationship among the viruses of the genus Flavivirus and to compare the classification based on molecular phylogeny with the existing serologic method. By using a combination of quantitative definitions (bootstrap support level and the pairwise nucleotide sequence identity), the viruses could be classified into clusters, clades, and species. Our phylogenetic study revealed for the first time that from the putative ancestor two branches, non-vector and vector-borne virus clusters, evolved and from the latter cluster emerged tick-borne and mosquito-borne virus clusters. Provided that the theory of arthropod association being an acquired trait was correct, pairwise nucleotide sequence identity among these three clusters provided supporting data for a possibility that the non-vector cluster evolved first, followed by the separation of tick-borne and mosquito-borne virus clusters in that order. Clades established in our study correlated significantly with existing antigenic complexes. We also resolved many of the past taxonomic problems by establishing phylogenetic relationships of the antigenically unclassified viruses with the well-established viruses and by identifying synonymous viruses.

The 1986 dengue and dengue hemorrhagic fever epidemic in Puerto Rico: epidemiologic and clinical observations

In 1986 Puerto Rico experienced its eleventh dengue outbreak of this century, but the first with simultaneous transmission of three dengue virus serotypes, and the first with significant numbers of severe and fatal hemorrhagic disease. Overall, 10,659 cases were reported; 1,257 cases were laboratory confirmed as having current or recent dengue infection. Dengue 4 (DEN-4) was the predominant serotype (160/363 isolates, 44%) followed by dengue 1 (DEN-1) with 134 isolates (37%) and dengue 2 (DEN-2), 69 isolates (19%). Transmission peaked during September, but large numbers of cases occurred through November. Seventy-one (91%) of Puerto Rico's 78 municipalities had laboratory-confirmed cases. Fifty-one percent of all confirmed cases occurred in metropolitan San Juan. Most cases presented clinically as classical dengue fever, but 37% of all confirmed cases were reported to have developed some type of hemorrhagic manifestation, and 6% reported hematemesis. In addition, 29 laboratory confirmed cases met the WHO case definition for dengue hemorrhagic fever, 3 of which were fatal. Among the 29 laboratory-confirmed cases of dengue hemorrhagic fever/ dengue shook syndrome, virus was isolated from 12; one DEN-1, three DEN-2, and eight DEN-4. Among laboratory confirmed cases, infants less than one year of age were at greater risk of developing dengue hemorrhagic fever/ dengue shook syndrome, hematemesis and any reported hemorrhage than were the other age groups evaluated.

Detecting bunyaviruses of the Bunyamwera and California serogroups by a PCR technique

Many bunyaviruses of the Bunyamwera and California serogroups are medically important human pathogens. The development of an effective technique to detect the viruses by using molecular biologic tools, such as PCR, improves not only clinical diagnosis but also virologic surveillance of mosquito vectors in the field. In this study, we evaluated eight pairs of primers for reactivity with 44 viruses of the genus Bunyavirus, using a reverse transcriptase PCR technique. With a pair of serogroup-specific primers we designed, all viruses of the serogroups tested could be detected. Further, virus-specific primer pairs were identified for California encephalitis virus, Jamestown Canyon virus, La Crosse virus, and snowshoe hare virus for use in North America. Using this technique, we could detect one La Crosse virus-infected mosquito in a pool of 100 mosquitoes with undetectable plaque titers.

Symptoms of dengue fever in relation to host immunologic response and virus serotype, Puerto Rico, 1990-1991

The authors investigated the role of secondary immunologic response, virus serotype, age, and sex on the clinical manifestations of dengue fever in Puerto Rico. From surveillance data for 1990 and 1991, this study identified 3,926 laboratory-positive cases, including 889 for whom dengue immunologic status and symptoms could be ascertained. Of those, 622 cases were virologically confirmed, and 267 cases were serologically confirmed. More than 50% of all positive patients reported fever, chills, headache, eye pain, body pains, joint pains, nausea, vomiting, or skin rash. The frequency of reporting signs, symptoms, and hospitalization was significantly higher among persons with secondary infections diagnosed by serological methods. Only rash was more common among those with primary infections. Symptom reporting increased with age; body pains, joint pains, and rash were significantly more frequently reported by female patients. No significant difference in symptom frequency was found among the virologically confirmed cases, comparing primary and secondary cases or infections due to different serotypes. The data for serologically confirmed cases suggest that in Puerto Rico the manifestations of dengue fever are, as with dengue hemorrhagic fever in Asia, more prominent among those who are experiencing secondary infections, and this effect may be more marked in the younger age groups.

Dengue severity throughout seasonal changes in incidence in Puerto Rico, 1989-1992. The Puerto Rico Association of Epidemiologists

To determine whether the proportion of severe dengue cases increased with the yearly seasonal increase in dengue incidence, we examined reports of disease symptoms in case surveillance data and laboratory testing results in Puerto Rico from January 1989 to July 1992. A computer algorithm was designed to identify severe cases, i.e., those that fulfilled three or all four of the World Health Organization criteria for dengue hemorrhagic fever (DHF). A monthly severity index (SI) was defined as the ratio of severe cases to laboratory-positive and indeterminate (all non-negative) cases for each month, while a more restrictive severity rate (SR) was defined as the ratio of severe laboratory-positive cases to the total number of laboratory-positive cases for each month. Monthly SI and SR were compared in two ways: within an epidemic cycle, and month-by-month. Linear regression analysis was performed over the monthly averages of the SI and SR. For a month-by-month examination of SI and SR, we examined the 43-month sequence by means of a linear model with autocorrelated disturbances. We found no statistically significant or cyclical change in the proportion of severe cases from month to month in this period. Our conclusions differ from the observations during the Cuban DHF epidemic of 1981, in which case severity was shown to increase markedly as the epidemic progressed; they agree with the conclusions of most previous studies in that dengue severity does not change significantly throughout a period of increased incidence.

A PCR-restriction enzyme technique for determining dengue virus subgroups within serotypes

The polymerase chain reaction (PCR) and restriction enzyme analysis were used to develop a rapid and simple procedure for identifying geographic subgroups of dengue virus within serotypes for epidemiologic investigations. The entire structural protein region of dengue viruses was amplified and the products were digested with the endonucleases AluI or DdeI. By comparing the restriction fragment length polymorphisms (RFLPs), we recognized dengue-2 and dengue-3 subgroups that corresponded to those previously determined by oligonucleotide fingerprinting or genomic sequencing. This procedure can be performed in 2 days without the use of radioisotopes, and results can be interpreted without computer analysis. For those analyses which require only subgroup affiliations, this is a useful tool for rapidly screening multiple virus isolates.

Cytokine responses to dengue infection among Puerto Rican patients

Recently, a strong correlation between high concentration of tumor necrosis factor (TNF alpha) in blood and severity of dengue hemorrhagic fever/dengue shock syndrome has been reported from Asia and the Pacific. We wished to determine if a similar relationship could be found in dengue patients in the Americas where adult patients with severe syndromes have been observed more frequently than in Asia where severe cases have been observed mostly among children. The concentrations of interleukin-1 (IL-1 beta) in hospitalized adult groups were significantly lower than that in outpatient adults. In contrast, the levels of interleukin 6 (IL-6) were significantly higher in hospitalized adults and children than in the corresponding outpatients. Levels of TNF alpha were higher in hospitalized children than in outpatient children or hospitalized adults. There was no significant difference in the levels of these three cytokines among hospitalized patients with or without hemorrhagic manifestations. Thus, an elevated IL-6 level was positively associated with severity of dengue infection in both children and adults, but IL-1 beta level was negatively associated with severity in adults.

Epidemic dengue 4 in the Yucatán, México, 1984

An outbreak of dengue 4 occurred in the Yucatán, México in 1984. During the course of the outbreak, 538 of 5486 reported cases of dengue-like illness were studied; 200 were confirmed as dengue serologically and/or virologically. Dengue 4 virus was isolated from 34 patients and dengue 1 from one. Severe haemorrhagic symptoms were observed in 9 laboratory confirmed patients, including four deaths. Thus, the outbreak in Yucatán is the second dengue epidemic in the Americas after the Cuban epidemic in 1981 in which a number of patients suffered from haemorrhagic complications. It was notable that 5 of 9 hospitalized, severe cases were young adults and that only one met the WHO criteria of DHF, in contrast to primary pediatric nature of DHF in Southeast Asia. In this paper we describe clinical, serologic, and virologic studies conducted during the outbreak.

Use of 'original antigenic sin' theory to determine the serotypes of previous dengue infections

Determination of serotypes of dengue viruses involved in sequential infections is important since, according to a theory of the pathogenesis of dengue haemorrhagic fever, a particular serotype may be a risk factor. It has been reported in Asia that at least the serotypes involved in the first infections could be serologically identified by the plaque reduction neutralization test (PRNT) because the highest PRNT titres after the second infections corresponded to the serotypes in the first infections. We re-examined the application of this theory of 'original antigenic sin' in Puerto Rico to evaluate its utility in serodiagnosis. Our results showed that it could not be applied reliably because of discrepant results.

Computer literature searches on dengue

Many research workers, to save time, rely entirely on either on-line or off-line databases offered by an increasing number of information services. The characteristics of eight databases, including five on-line services, were analysed in the present study concerning the retrieval of information on dengue, the most important mosquito-borne viral disease of humans. Differences in the rate of retrieval among data-bases were apparent, depending on the main subject of publication as well as on the geographical location of the publisher. While rates of retrieval of references in molecular biology were generally satisfactory (mostly > 70%), those in clinical medicine and epidemiology were not (< 50%). The latter, as published in many dengue-endemic tropical countries, were found to be inadequately covered. For the global surveillance of dengue, which has increased in intensity and spread to many countries because of increased international travel, the development of a new database emphasizing tropical geographic medicine is highly desirable.

An ELISA procedure for the diagnosis of dengue infections

Although the hemagglutination-inhibition (HI) test has been the standard test used by the World Health Organization (WHO) for the classification of serologic response in dengue infections, it is slow, requiring paired specimens. Furthermore, not all investigators have accepted the classification. Thus, there is an urgent need to develop a rapid test which employs a single specimen. We developed an enzyme-linked immunosorbent assay (ELISA) for rapid classification of serologic responses in dengue infections based on the ratio of IgM and IgG in a single specimen. Using the criteria established by the WHO (1986) for comparison, concordant results were obtained in 81% and 95% of primary and secondary infections, respectively, when serum specimens were tested as pairs. When tested as single specimens, the diagnoses by ELISA and HI agreed in 41% and 52% of acute specimens of primary and secondary infections, respectively. The lower rate of concordance in acute-phase samples was due to the absence of detectable IgM in acute specimens collected at outpatient clinics. On the other hand, diagnoses by ELISA and HI agreed in 79% and 95% of primary and secondary infections when single convalescent specimens were used. Analysis of the discordant results between the two tests revealed that the interpretation by the IgM-IgG ratio agreed better with HI classifications practised by some investigators than it did with the WHO.

Study of anti-dengue NS1 antibody by western blot

The presence of anti-nonstructural protein (NS1) antibody in natural dengue infections has been suspected to be associated with development of dengue haemorrhagic fever (DHF). The Western blot technique was used to study the dynamics of the immune response to NS1 and to determine the frequency of anti-NS1 antibody among confirmed dengue patients in Indonesia, where DHF is common, and in Puerto Rico, where DHF is less frequently observed. Anti-NS1 antibody was rarely found in those with primary infections in either group. The antibody occurred at a significantly higher frequency in acute-phase serum samples from secondary infections in Indonesia than in those from Puerto Rico. No difference was observed, however, in Indonesian patients with secondary infection who had dengue fever or DHF.

Maintaining mosquito cell lines at high temperatures: effects on the replication of flaviviruses

The upper thermal limit for maintenance of eleven mosquito cell lines was studied. Although most cell lines could be grown at 32 degrees C to 34 degrees C, Anopheles stephensi cell line could be maintained at 37 degrees C. At higher temperatures initial growth rate was higher, but yield of cells after about a week of incubation was lower than at the standard temperature (28 degrees C). Replication of several flaviviruses in Aedes albopictus cell cultures adapted to 34.5 degrees C was faster, and viral titers were higher than at 28 degrees C.

Detecting artificial anti-dengue IgM immune complexes using an enzyme-linked immunosorbent assay

A variety of methods have been employed to detect viral immune complexes (IC) in clinical specimens. However, most techniques used were not antigen-specific. We developed a simple, specific double antibody sandwich technique to detect artificial anti-dengue (DEN) IgM immune complex (IgM-IC). Positive reactivity with IgM-ICs prepared with live DEN-1, -2, and -3 viruses was found to be related to IgM titers exceeding 1:20 and to the titer of the viruses. Most IgM-ICs prepared with live DEN-4 virus did not react. In contrast, IgM-ICs prepared with hemagglutination antigens, representing all 4 serotypes, reacted positively with amounts of antigens ranging from 2 to 8 units. These IgM-ICs were not type-specific.

Dengue 3 virus transmission in Africa

The first known transmission of dengue 3 virus in Africa was documented by virus isolation during an epidemic of dengue-like illness in Pemba, Mozambique, in late 1984 and early 1985. Dengue 3 virus was the only serotype isolated. Most patients appeared to be experiencing secondary flavivirus infections, but whether this was the result of previous dengue, yellow fever, or other flavivirus infection is not known. Two cases of hemorrhagic disease with shock and death were associated with the epidemic.

Antigen capture ELISA for the identification of dengue viruses

We developed a simple antigen capture enzyme immunosorbent assay (AgC-ELISA) for identifying dengue (DEN) virus. The method employed serotype-specific monoclonal antibodies as capture antibodies and an enzyme conjugate of a flavivirus-reactive monoclonal antibody as a detecting antibody. Most DEN virus strains, representing all 4 serotypes isolated from various parts of the tropics, were identical either visually of spectrophotometrically when infected cell culture fluids were used as sources of antigen. The shelf life of the solid phase presensitized with monoclonal antibodies was 4 mth at -15 degrees C. DEN prototype viruses were still identified after storage at -15 degrees C for 1 yr or at room temperature for 1 mth.

Low rates of antigen detection and virus isolation from the peripheral blood leukocytes of dengue fever patients

We evaluated direct fluorescent antibody (FA) testing of peripheral blood leukocytes (PBL) from patients in Puerto Rico with serologically and/or virologically confirmed dengue fever as a possible rapid diagnostic test and compared rates of dengue virus isolation from PBL with the rates from plasma or serum using the mosquito inoculation technique. Dengue antigen was detected in the PBL of only 1 of 19 patients with confirmed dengue. Virus was isolated from 3 of 19 PBL specimens and from 6 of 19 acute-phase serum or plasma samples. Four viruses were obtained from serum or plasma only and 1 isolate came from PBL only. We conclude that FA testing of PBL from dengue fever patients has little promise as a rapid diagnostic technique. Despite small numbers, our data suggest that virus isolation from PBL is less sensitive than that from serum or plasma. Our results differ considerably from those of previous studies of dengue hemorrhagic fever patients conducted in Thailand.