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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 outbreak 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 AmericasAvailable 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 aegyptiAedes albopictus
Aedes aegyptiAedes albopictus
Urban cycleSylvatic 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.comTires
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 HillsU.S. Centers for Disease Control and PreventionEmail: [email protected]
AcknowledgementsDr Bertrand SudreEuropean Center for Disease Control and Prevention
Dr Ann PowersU.S. Centers for Disease Control and Prevention
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