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Overview of West Nile Virus and Sandfly-Borne Phlebovirus Infections in Anatolia

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Overview of West Nile Virus and Sandfly-Borne Phlebovirus Infections in Anatolia Journal of Microbiology and Infectious Diseases / 2014; Special Issue 1: S22-S31 JMID doi: 10.5799/ahinjs.02.2014.S1.0138 REVIEW ARTICLE Overview of West Nile Virus and Sandfly-borne Phlebovirus Infections in Anatolia Koray Ergünay1, Zeliha Koçak Tufan2 1 Hacettepe University Faculty of Medicine, Department of Medical Microbiology, Virology Unit, Ankara, Turkey 2 Yildirim Beyazit University, Ankara Ataturk Training & Research Hospital, Infectious Diseases & Clinical Microbiology Department, Ankara, Turkey ABSTRACT Arthropod-borne (arbo) viruses are trafinsmitted to the susceptible hosts by blood-feeding arthropods such as mosqui- toes, sandflies and ticks. Arboviral infections have had a significant global public health impact during the last decades due to their resurgence and dynamic epidemiologic features. In Turkey, cases and outbreaks due to previously underes- timated arboviral infections have emerged since 2009. In this manuscript, previous and current data on two of the major arboviral infections, West Nile virus and Sandfly-borne Phleboviruses have been overviewed with a special emphasis on clinical presentation and laboratory evaluation. J Microbiol Infect Dis 2014; Special Issue 1: S22-S31 Key words: Arboviruses, West Nile Virus, WNV, Phlebotomus fever, Phlebovirus, Turkey Türkiye’de Batı Nil Virusu ve Flebovirus Enfeksiyonlarına Genel Bakış ÖZET Artropod kaynaklı (arbo) viruslar, duyarlı konaklara sivrisinek, kum sineği ve kene gibi artropodların kan emmesi yoluyla bulaşır. Son yıllarda yeniden ortaya çıkan ve epidemiyolojik özelliklerinde değişiklikler izlenen çeşitli arboviral enfeksi- yonlar, tüm dünyada önemli halk sağlığı sorunları oluşturmaktadır. Türkiye’de 2009 yılından günümüze, daha önce dikkat çekmemiş bazı arboviruslara bağlı olgular ve salgınlar ortaya çıkmıştır. Bu derlemede, iki önemli arbovirus olan Batı Nil virusu ve kum sineği (tatarcık) kaynaklı fleboviruslarla ilgili ülkemize ait veriler, klinik ve laboratuvar bulguları özellikle vurgulanarak ele alınmaktadır. Anahtar kelimeler: Arboviruslar, Batı Nil Virusu, BNV, Filebotomus ateşi, Filebovirus, Türkiye INTRODUCTION regions. The geographic distribution of both vectors and viruses has exhibited a global expansion, ac- Arthropod-borne (arbo) viruses are transmitted to companied by more frequent and intense epidem- the susceptible hosts by blood-feeding arthropods ics, influenced by the interaction of many factors such as mosquitoes, sandflies and ticks. There such as global warming, demographic changes are over 530 viruses registered in the International and modern transportation. Many arboviruses have Catalogue of Arboviruses, where 134 have been become established in new geographic locations documented to cause illness in humans. Arbovi- where susceptible vectors and hosts provide per- ruses are taxonomically diverse, belonging to eight missive conditions.1,2 viral families and 14 genera. During the last three decades, there was a dramatic global emergence/ Turkey is located in the northeastern part of the resurgence of arboviral diseases. Although some Mediterranean region and is included in the endem- arboviruses that cause human disease have been ic zone for various arboviruses. Arboviral diseases newly recognized, the greatest problem has been in Turkey have gained considerable attention follow- the resurgence of diseases that were once thought ing the emergence of Crimean Congo hemorhagic to be controlled or confined to distinct geographic fever. However, evidence for the circulation of other mosquito and sandfly-borne viral infections with sig- Correspondence: Koray Ergünay, Hacettepe University Faculty of Medicine,Department of Microbiology and Clinical Microbiology, Virology Unit, Morphology Building 3rd floor, Sihhiye, Ankara, Turkey Email: [email protected] Received: 16 August 2013, Accepted: 10 November 2013 Copyright © Journal of Microbiology and Infectious Diseases 2014, All rights reserved Ergünay K and Tufan Z K. West Nile and Phleboviruses in Anatolia S23 nificant public health impact are also present.3 In in patients with immune suppression, under chemo- this review, we aim to discuss current data on two therapy and in transplant recipients.4-6 of the major arboviral infections that have triggered WNV infections have been documented in outbreaks as well as case clusters since 2009 in northern Africa, Israel, India, Australia, and Europe. Turkey, West Nile virus and Sandfly-borne Phlebo- WNV has emerged in the United States in 1999 and viruses with a special emphasis on clinical presen- has progressively spread in the American continent tation and laboratory evaluation. thereafter.6 Since 1994, the virus has caused out- breaks of severe neuroinvasive disease in humans WEST NILE VIRUS and horses in Europe and the Mediterranean Ba- sin.7 Various genetic lineages of WNV have been West Nile virus (WNV) is an enveloped positive- identified, the prominent being lineages 1 and 2. The sense RNA virus, classified in the Japanese en- majority of the strains responsible of the European cephalitis serocomplex of the Flavivirus genus with- and the Mediterranean Basin outbreaks belonged in in the family Flaviviridae. In nature, WNV is main- Lineage 17 Turkey is located in the endemic zone tained within an enzootic cycle between various for WNV in the Old World. bird species as amplifying hosts and ornithophilic mosquito vectors. Humans, horses, and other mam- Seroepidemiology and Vector Surveillance in mals mostly become infected by blood sucking of Anatolia infected mosquitoes. However, they are considered as incidental or dead-end hosts for WNV that do not Serosurveillance efforts in blood donors and vari- contribute to the virus life cycle, due to insufficient ous mammalian species have provided evidence 3 levels of viremia observed in these species. Blood for widespread WNV exposure in Anatolia. The transfusion and organ transplantation from viremic inital evidence for WNV circulation in Anatolia has donors have also been identified as potential trans- been provided over three decades ago, in 1971, af- mission routes as well as documented laboratory- ter an investigation of antibodies against various ar- acquired infections. Moreover, cases due to intra- thropod-borne viruses performed via hemagglutina- uterine virus transmission and breast-feeding have tion inhibiton (HI) method followed by confirmation 8 been reported.4,5 by neutralization. This study revealed antibodies against WNV in 20% and 0.9% of sheep from Anka- In the majority of the individuals exposed to ra (Central Anatolia) and Hatay (Southern Anatolia) WNV, asymptomatic seroconversion or subclinical provinces, respectively. Animal and human WNV infections occur, whereas a febrile illness called exposure in Aegean and Southeast Anatolia were “West Nile Fever” develops in 20% and WNV neu- suggested in the following studies.9,10 However, high roinvasive disease (WND) in less than 1% of the seroprevalence rates (42.8% in various provinces affected individuals. West Nile fever is character- of Southeastern Anatolia) reported in these stud- ized by abrupt onset of fever, headache, backache, ies are probably due to serological cross-reactions malaise, anorexia, myalgia, chills, vomiting, rash, commonly observed in assays that detect group- fatigue, and eye pain. While a wide range of clinical specific antibodies, such as HI.11 Human WNV ex- presentations can be observed in WND with signs posure in the Aegean border of Anatolia was verified and symptoms of meningitis, encephalitis and my- in 1980, by the demonstration of WNV specific anti- elitis, more than half of the persons display signs, bodies in 21.5% of the sera collected from residents symptoms, or laboratory evidence of brain paren- of the region.12 Moreover, virus activity was also chymal involvement and are classified as encepha- confirmed in Southeast Anatolia in 2007, where the litis. WNV-associated encephalitis is reported to oc- presence of WNV neutralizing antibodies was re- cur more frequently in persons over 55 years and vealed in.9 4% of the individuals from Sanliurfa and in those with underlying immunosuppression, his- Siverek provinces.13 In a recent survey performed in tory of hypertension and/or cardiovascular disease. Kızıltepe region of Mardin province, the neutralizing WNV-related diseases are frequently diagnosed via antibody seroprevalence was reported as 17%, age detection of specific immunoglobulins. Detection of over 50 and certain occupational risk groups were viral RNA via polymerase chain reaction (PCR) in identified as risk factors for virus exposure.14 These clinical specimens is possible within a few days af- cross-sectional data from residents obtained in vari- ter onset, due to the rapid clearance of the virus. ous dates and research groups clearly demonstrate However, prolonged viremia without detectable im- the circulation of WNV in South-Southeast Anato- munoglobulins has been noted in rare cases and lia where clinicians and public health officials must J Microbiol Infect Dis www.jmidonline.org Special Issue 1, 2014 S24 Ergünay K and Tufan Z K. West Nile and Phleboviruses in Anatolia consider WNV as suspected agent among cases many other mosquito species with vector capac- with febrile and/or neuroinvasive diseases of unde- ity for WNV are also exist.24 The number of stud- termined etiology and appropriate testing should be ies involving virus surveillance in probable vectors performed in probable cases. from Turkey are limited. In a region with serolog- A serosurvey undertaken
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