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6/ 24/ 2019 National Center for Emerging and Zoonotic Infectious Diseases National Center for Emerging and Zoonotic Infectious Diseases The Story of Mosquito Borne Viruses that Cause Joint Pain Epidemiology of Arthritogenic Arboviruses among

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National Center for Emerging and Zoonotic Infectious Diseases

Epidemiology of Arthritogenic Arboviruses Affecting Travelers

Susan Hills MBBS, MTH Medical Epidemiologist Division of Vector‐Borne Diseases Centers for Disease Control and Prevention

16th Conference of the International Society of Travel Medicine June 8, 2019

National Center for Emerging and Zoonotic Infectious Diseases

The Story of Mosquito‐Borne Viruses that Cause Joint Pain among Travelers What: Alphaviruses

Sindbis virus

Symptoms of alphaviral diseases Why is clinician awareness of these diseases important?

  • Disease burden

– Common: Chikungunya – Less common: Ross River, Mayaro, O’nyong‐nyong, Sindbis

  • Geographically widely distributed

Robinson MC. Trans Roy Soc Trop Med Hyg 1955

Potential for rapid spread

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Travelers can be sentinels of infection

Tsuboi 2016. Emerging Infectious Diseases

Traveler’s role in spread of infection

Lindh E. Open Forum ID 2018

Chikungunya

Chikungunya

  • First recognized during
  • utbreak in Tanzania in

1952–53

  • ‘that which bends up’ or

‘to become contorted’ (Makonde language)

Source: PAHO, 2011. Preparedness and Response for Chikungunya Virus Introduction in the Americas Available at www..paho.org

Transmission cycle

Chimpanzees, monkeys, baboons Chimpanzees, monkeys, baboons Aedes furcifer, Aedes africanus Aedes furcifer, Aedes africanus

Acknowledgement for graphic: Dr Ann Powers, CDC

Sylvatic cycle

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Transmission cycle

Chimpanzees, monkeys, baboons Chimpanzees, monkeys, baboons Aedes furcifer, Aedes africanus Aedes furcifer, Aedes africanus

Acknowledgement for graphic: Dr Ann Powers, CDC

Aedes aegypti Aedes albopictus Aedes aegypti Aedes albopictus

Urban cycle Sylvatic cycle

Mosquito vectors

Aedes aegypti Aedes albopictus

  • Identified by white stripes on bodies and legs
  • Aggressive daytime biters with peak dawn and dusk
  • Breed in containers that hold water

Spread of chikungunya virus since 2004*

Source: Zeller H et al. J Infect Dis 2016

*As of 2015

Chikungunya virus disease cases reported among travelers, United States, 2009–2018 – Risk area for chikungunya virus transmission*

*As of May 2018 www.cdc.gov

Travel destination for U.S. travelers with chikungunya virus disease, 2018–19* –

* Preliminary data for 126 travelers reported to ArboNET with travel destination noted

Asia (59%) Caribbean (15%) South America (10%) Africa (6%) Central America (6%) North America (5%) Pacific (2%)

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  • Sweden
  • Switzerland
  • United Kingdom

Eurosurveillance, March 2019

  • Romania
  • Israel
  • France

Travelers do not need to travel far to be at risk

Ross River virus infection

Ross River virus

First isolated: Ross River, Townsville, Australia, 1959 Primary vectors: Aedes and Culex species mosquitoes Reservoir hosts: Marsupials

Risk areas

  • Australia

– Average of 5,000 cases/year with periodic outbreaks

  • Papua New Guinea

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Additional risk areas – Pacific Islands region

  • Large outbreak South Pacific in 1979–1980
  • Locally, no outbreaks or cases reported since
  • Data suggest Ross River virus might be established or be

periodically reintroduced with local transmission

– Traveler cases from 1997–2009 in tourists to Fiji – Serosurvey evidence in French Polynesia and American Samoa

Proll 1999. Dtsch Med Wochenschr; Klapsing 2005. Emerging Infectious Diseases; Lau 2012. Travel Medicine Infectious Diseases; Aubry 2015. International Journal of Infectious Diseases; Lau 2017, International Journal of Infectious Diseases.

Ross River virus infections in travelers to Australia

  • Reported in small numbers but regularly

Mayaro virus infection

Mayaro virus

First isolated: Mayaro County, Trinidad, 1954 Primary vectors: Haemagogus species mosquitoes* Reservoir hosts: Non‐human primates*

Venezuela

*Presumed

Countries with reported Mayaro cases

Source: Adapted from Acosta‐Ampudia Y et al, 2018. Emerging Microbes & Infections 7:163

Source: Flickr.com Source: divergenttravelers.com Source: amazon‐rainforest.org

Human exposure and infection

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Published cases in international travelers, 1996–2018

Year Nationality Travel destination Reference 1996 United States Peru 1 1997 United States Peru 1 1999* United States Bolivia 2 2008** Dutch Suriname 3 2010 French Brazil (Amazon) 4 2011 Swiss Peru (Amazon) 5 2012 German Bolivia (Amazon) 6 2013 German French Guiana 7 2013 Dutch Brazil (Amazon) 8 2013 French French Guiana 9 2014 German Ecuador 10 2014 German Bolivia 10

References: 1. Tesh et al, 1999. Clin ID; 2. Taylor et al, 2005. Southern Med J; 3. Hassing et al, 2010. J Infect; 4. Receveur et al, 2010. Euro Surveill; 5. Neumayer et al, 2012. Emerg ID; 6. Theilacker et al, 2013. BMC Infect Dis 7. Friedrich‐Janicke et al, 2014. Emerg ID. 8. Slegers et al,

  • 2014. J Clin Virol; 9. Llagonne‐Barets et al, 2016. J Clin Virol; 10. Tappe et al, 2016. Emerg ID.

*Probable case; **Possible infection in partner also

O’nyong‐nyong virus and Sindbis virus infection

O’nyong‐nyong*

First isolated: Uganda, 1959 Primary vectors: Anopheles species mosquitoes Vertebrate hosts: Unknown

* ‘Very painful weakening of the joints’

Geographical distribution of O’nyong‐nyong virus

Source: Rezza et al, 2017. Pathogens and Global Health

O’nyong‐nyong cases in travelers Sindbis

First isolated: Sindbis district, Egypt, 1952 Primary vectors: Culex, Aedes, and Culiseta species mosquitoes Vertebrate hosts: Birds

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Geographical distribution of Sindbis virus

Source: Adouchief et al, 2016. Reviews in Medical Virology

Summary

  • Chikungunya: most common disease causing arthralgia in

tropical/subtropical areas

  • Other alphaviruses to keep in mind

– Australia and the Pacific: Ross River virus disease – Africa: O’nyong‐nyong – South/Central America: Mayaro – South Africa, Northern Europe: Sindbis

Why are arboviruses emerging?

..and covering greater distances with increasing speed

Human travel

Increasing number and variety of destinations …allowing rapid transport of pathogens

Growth in tourist numbers Spread of vectors

Predicted distribution of Aedes albopictus Predicted distribution of Aedes aegypti

  • Adaptable to a range of habitats
  • Adaptable to cold temperatures

Source: Kraemer et al, 2015. eLife

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International trade

Lucky bamboo

Source: Walmart.com

Tires

Viral adaption

Aedes albopictus

  • Chikungunya virus

developed a mutation that allows easier transmission by Aedes albopictus

Urbanization

  • Urbanization of human

populations

Source: pxhere.com

Climate change

  • Appropriate vector
  • Vertebrate host

What next?

  • Suitable environmental conditions
  • Susceptible population

What is needed?

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Susan Hills U.S. Centers for Disease Control and Prevention Email: shills@cdc.gov Acknowledgements Dr Bertrand Sudre European Center for Disease Control and Prevention Dr Ann Powers U.S. Centers for Disease Control and Prevention

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