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National Center for Emerging and Zoonotic Infectious Diseases National Center for Emerging and Zoonotic Infectious Diseases

The Story of ‐Borne Viruses that Cause Joint Pain Epidemiology of Arthritogenic Arboviruses among Travelers 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 12

What: Alphaviruses Symptoms of alphaviral diseases

Sindbis virus

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Why is clinician awareness of these diseases important? Potential for rapid spread

. Disease burden – Common: –Less common: Ross River, Mayaro, O’nyong‐nyong, Sindbis

. Geographically widely distributed

Robinson MC. Trans Roy Soc Trop Med Hyg 1955

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Travelers can be sentinels of infection Traveler’s role in spread of infection

Lindh E. Open Forum ID 2018

Tsuboi 2016. Emerging Infectious Diseases

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Chikungunya

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Chikungunya Transmission cycle Sylvatic cycle

. First recognized during Aedes furcifer, Aedes africanus outbreak in in 1952–53 . ‘that which bends up’ or Chimpanzees, monkeys, Chimpanzees, ‘to become contorted’ baboons monkeys, baboons (Makonde language)

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

Acknowledgement for graphic: Dr Ann Powers, CDC

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Transmission cycle Mosquito vectors Sylvatic cycle Urban cycle

Aedes aegypti Aedes furcifer, Aedes africanus Aedes albopictus

Chimpanzees, monkeys, Chimpanzees, baboons monkeys, baboons Aedes aegypti Aedes albopictus

. Identified by white stripes on bodies and legs Aedes aegypti Aedes furcifer, Aedes africanus Aedes albopictus . Aggressive daytime biters with peak dawn and dusk

. Acknowledgement for graphic: Dr Ann Powers, CDC Breed in containers that hold water

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Chikungunya virus disease cases reported among Spread of chikungunya virus since 2004* travelers, United States, 2009–2018 –

*As of 2015 Source: Zeller H et al. J Infect Dis 2016 15 16

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

North America (5%) Pacific (2%) Central America (6%)

Africa (6%)

South America (10%) Asia (59%)

Caribbean (15%)

* Preliminary data for 126 travelers reported to ArboNET with travel destination noted *As of May 2018 www.cdc.gov 17 18

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Travelers do not need to travel far to be at risk

Eurosurveillance, March 2019

. Sweden . Romania . Switzerland . Israel . United Kingdom . France

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Ross River virus infection Ross River virus

First isolated: Ross River, Townsville, Australia, 1959

Primary vectors: Aedes and Culex species mosquitoes

Reservoir hosts: Marsupials

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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 Ross River virus infections in travelers to Australia

. Reported in small numbers but regularly . 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.

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Mayaro virus

Mayaro virus infection First isolated: Mayaro County, Trinidad, 1954

Primary vectors: Haemagogus species mosquitoes*

Venezuela Reservoir hosts: Non‐ primates*

*Presumed

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Countries with reported Mayaro cases Human exposure and infection

Source: Flickr.com

Source: divergenttravelers.com

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

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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 O’nyong‐nyong virus and 2011 Swiss Peru (Amazon) 5 2012 German Bolivia (Amazon) 6 2013 German French Guiana 7 Sindbis virus infection 2013 Dutch Brazil (Amazon) 8 2013 French French Guiana 9 2014 German Ecuador 10 2014 German Bolivia 10 *Probable case; **Possible infection in partner also

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. 31 32

O’nyong‐nyong* Geographical distribution of O’nyong‐nyong virus

First isolated: , 1959

Primary vectors: Anopheles species mosquitoes

Vertebrate hosts: Unknown

* ‘Very painful weakening of the joints’ Source: Rezza et al, 2017. Pathogens and Global Health

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O’nyong‐nyong cases in travelers Sindbis

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

Vertebrate hosts: Birds

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Geographical distribution of Sindbis virus 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 –, Northern Europe: Sindbis

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

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Human travel Why are arboviruses emerging?

..and covering greater distances with increasing speed

Increasing number and variety of destinations

…allowing rapid transport of pathogens

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Growth in tourist numbers Spread of vectors

Predicted distribution of Aedes albopictus Predicted distribution of Aedes aegypti

Source: Kraemer et al, 2015. eLife

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

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International trade Viral adaption

. Chikungunya virus developed a mutation that allows easier transmission by Aedes albopictus

Lucky bamboo Tires Source: Walmart.com

Aedes albopictus

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Urbanization Climate change

• Urbanization of human populations

Source: pxhere.com

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What next?

What is needed?

. Appropriate vector . Suitable environmental conditions . Vertebrate host . Susceptible population

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Acknowledgements Dr Bertrand Sudre European Center for Disease Control and Prevention Dr Ann Powers U.S. Centers for Disease Control and Prevention

Susan Hills U.S. Centers for Disease Control and Prevention Email: [email protected] 49

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