Emerging Viral Infections Phleboviruses

Emerging viral infections Phleboviruses

Anna Papa National ReferenceESCMID Centre Online for Arboviruses Lecture and Hemorrhagic Library Fever viruses Aristotle University of Thessaloniki, Greece Main vectors of phleboviruses: phlebotomine sandflies

Etymologia. Phlebotomus: from the Greek words phleboESCMID + tomi=opening Online a vein Lecture Library TAXONOMY Phleboviruses: arthropod-borne RNA viruses Genus Phlebovirus - Family Bunyaviridae Cause to humans symptoms ranging from short self limiting fever to encephalitis and fatal hemorrhagic fever.

70 antigenically distinct serotypes: • Sandfly Fever group – 55 serotypes (most transmitted by sandflies, few by mosquitoes, e.g. Rift Valley fever) •Uukuniemi group – 13 serotypes (transmitted by ticks). • Severe fever and thrombocytopenia syndrome (SFTS) virus (transmitted by ticks). © by author 9 antigenic complexes including 37 classified viruses. Species differentiation based on a 4-fold difference in neutralization tests. High rate of genetic reassortment of the M segment: relying only on neutralizationESCMID or hemagglutination Online Lectureinhibition assays Library is not enough. VIRION

Enveloped, spherical. Diameter 80-120 nm. Glycoproteins serve as neutralizing and hemagglutinin-inhibiting antibody targets and are exposed to selective pressure.

GENOME Segmented negative- stranded RNA genome. Encodes for © by author 6 proteins.

S : N protein and a NSs. Uses an ambisense coding strategy ESCMIDM Online : precursor of Lecturethe viral glycoproteins Library Gn and Gc , and NSm. L : viral RNA polymerase. Phlebotomine sandflies (Psychodidae)

• > 500 different species

• Widely distributed in Med countries from May to September. The number increases after rainy season.

• Abundant in peri-urban and rural environments, close to domestic animals and human populations.

• A cool, shaded, slightly damp The sandfly becomes infected environment is ideal for the sandfly life. when biting an infected human in © by author the period between 48 h before • Active during night - silent flight - short the onset of fever and 24 h after flight range. the end of the fever, and remains infected for its lifetime ESCMID Online• Only Lecture females bite! Library Phleboviruses are of great military importance since large number of invading non-immune persons may be incapacitated at the time when they are mostly needed.

Sabin et al. Phlebotomus (Papatassi or sandfly) fever, a disease of military importance. Summary of existingESCMID knowledge and Online preliminary reportLecture of original investigations.Library JAMA 1944 Sandfly fever viruses: Historical perspectives

1908: Austrian military commission (Doerr et al) working on the Dalmatian coast investigated the etiology and transmission of sandfly fever. Vector: P. papatasi . Before World War I: British investigators in Malta. During World War II: 8,500 cases among US soldiers in the Sicily campaign (summer 1943), Naples outbreak (summer 1944). 1943-44: Isolation of Sicilian and Naples strains from patients in Palermo, Sicily and Naples (Sabin). August 1944: First use of DDT for the control of malaria vectors, decrease of SF cases. 1948: the largest outbreak occured© by in Serbiaauthor (>1 million cases). 1971: Isolation of TOSV from P. perniciosus in Tuscany, Italy. 1983: Association of TOSV with neurologic disease. ESCMID Online Lecture Library Although sandflies are widely distributed, most sandfly fever cases occur around the Meditteranean Basin.

Meditteranean Sea © by author

The incidence of SF in the Americas is relatively low. The sandflies there are sylvan and do not enter houses to bite people. ESCMID Online Lecture Library The exact epidemiology of each species is not well understood because: -asymptomatic or mild febrile cases are significantly more prevalent than previously suspected - the identity of the virus cannot be assessed with certainty (cross-reactions).

Three human pathogenic phleboviruses are distributed in the Mediterranean countries : Toscana virus (TOSV) - Sandfly fever Naples virus (SFNV) - Sandfly fever Sicilian virus (SFSV).

SFSV and SFNV cause a transient febrile illness. TOSV is neurovirulent, leading to aseptic meningitis and meningoencephalitis. ESCMID Online Lecture Library Sandfly fever

Phlebotomus fever, papataci fever, 3-day fever

A few days (2-5) after the infective bite, a feeling of lassitude, abdominal distress and chills develop followed by high fever, severe frontal headaches, muscle and joint pain, flushing of the face, conjunctiva injection, and tachycardia. After 2 days the fever begins to subside and the temperature returns to normal. Fatigue, depression, bradycardia and subnormal blood pressure may persist from few days to several weeks. Recovery is usually complete. © by author Similar symptoms to dengue fever, but without rash.

ESCMID Online Lecture Library Toscana virus infections

- Asymptomatic - Influenza-like syndrome - Meningitis or meningoencephalitis in summer

May to October, with peak in August. Central Italy: 80% of acute CNS viral infections in children and 50% of cases in adults during summer.

Central Anatolia, Turkey: 15.7% of aseptic meningitis.

Portugal: 5.6% of meningitis cases.

Seroprevalence varies among countries and among regions of a country.

Italy: 3% in northern Italy (Torino), to© 16% by in Umbriaauthor and 22% in central Italy. Spain: 5% to 26%. France (south-eastern ):12% in blood from donors. Turkey: 17.8% Cyprus: 20%,ESCMID Greece 50% in OnlineIonian islands Lecture Library TOSV genotypes

S segment Italian – Spanish group 13.2% at nt level Spanish group

French strains © by author Italian group

* TOSV detectedESCMID in central Anatolia,Online Turkey, Lecture clusters in the Library Italian group Laboratory diagnosis of phleboviral infections

Virus isolation RT-PCR (only in the first 1-2 days after symptom onset and before the IgM detection). Serology (cross reactions exist within the antigenic complex). Neutralization assays on early convalescent sera are the reference method to identify the viruses or to assess the antibody response specificity.

ESCMID Online Lecture Library Prevention  Prevention of sandfly bites (insect repellents)  Control of sandflies and their breeding grounds with insecticides

Time: May to September 2002 Place: Cyprus, Athalassa National Forest Park, 5km SE of Nicosia Patients: 256/581 (44%) soldiers of the Greek Army forces, 17-22 y. Signs and Symptoms: high fever (39-41oC), headache, rigors, arthralgia, myalgia, lower back pain. Duration of symptoms: 60-72 h. Post infectious asthenia sydrome (2 weeks) Laboratory findings: leucopenia, monocytosis, 2X elevated transaminases (mainly ALAT) © by author Laboratory diagnosis: Genetic detection of a SFSV-like strain (Cyprus virus) Isolation in Vero E6 cells ESCMIDSerological Online cross-reactivity Lecture for phleboviruses Library Cyprus virus isolated from patient’s blood on the 1st day of illness

0 24h 48h

δ=100 nm ESCMID Online Lecture Library Phylogenetic tree including Cyprus virus (partial L segment)

Cyprus – Sicilian: 6.7% at nt level © by author1.5% at aa level

ESCMID Online Lecture Library Turkey

Summer of 2007 and 2008 Turkey in Kozan and Izmir in Med Turkey, and Ankara in central Turkey. © by author A SFSV-like strain was isolated (SFTV) highly homologous to Cyprus virus.

ESCMID Online Lecture Library France

Massilia virus MASV has been isolated from P. (L.) perniciosus in 2005 in two localities in SE France. It is most closely related to viruses in the SFNV complex. So far there are no reports of human disease from this virus. © by author

ESCMID Online Lecture Library Algeria

July 2006. 460 sandflies. 1/24 pools phlebo-positive. P. ariasi. Closer to Cyprus virus.

July 2007. 785 sandflies. 3/40 pools phlebo-positive. © by authorTwo sequences from P. longicuspis closer to Poona virus of SFNV. One from P. papatasi in Kabylia closer to Cyprus virus rather than the Algerian strain from P. ariasi ESCMID Online Lecturediscovered Library in 2006. Tunesia SFN-like virus

SFS-like virus

Sandfliy collection from two sites, Utique and Felta, corresponding to different bioclimatic zones © by author 1489 sandflies (75 pools) 10/75 pools contained phlebovirus RNA Overall ESCMIDprevalence of phlebovirus Online infection Lecture 0.67% Library (10/1489).

Punique virus: member of the SFNV complex, most closely related to MASV. Genetic distance of Punique virus and all other members of the SFNV complex: 25–29 %.

Sandflies of the subgenus Larroussius (P. perniciosus, P. perfiliewi and P. longicuspis)

Mostly in sandflies from the subgenus Larroussius (P. perniciosus, P. longicuspis and © by author P. major)

Mostly in P. papatasi (subgenus Phlebotomus) ESCMID Online Lecture Library Granada virus (GRV), was isolated from female sandflies collected in June 2004 in Alfacar, Granada, SE Spain. GRV infects humans (detection of neutralizing antibodies). Not known whether it can be implicated in human disease. Likely to be a natural reassortant of MASV(donor of the L and S segments) with a yet unidentified phlebovirus (donor of the M segment). © by author

ESCMID Online Lecture Library New phleboviruses in the Americas

Aguacate virus: 10th serogroup or species in Phlebovirus genus? Central and South America: Aguacate virus, a tentative species of the genus Phlebovirus, and three other unclassified viruses, Armero virus, Durania virus and Ixcanal virus, demonstrate a close relationship to one another. They are distinct from the other 9 recognized species within the genus Phlebovirus. Aguacate virus appears to be a natural reassortant and serves as one more example of the high frequency of reassortment in this genus.

Geographic distribution of Candiru Antigenic Complex, a highly diverse and reassorting © by author group of viruses affecting humans in Central and North America ESCMID Online Lecture Library

SFTSV or Huaiyangshan virus

Since 2007 many cases of a life-threatening disease with sudden fever, gastrointestinal symptoms, thrombocytopenia, and leukopenia were reported in Henan and Hubei provinces, China. After that the virus was detected in additional provinces. Fatality 30%. Patients reported of tick bites. © by author A novel phlebovirus was identified designated SFTS bunyavirus. Although closely related to Uukuniemi virus, this virus was distinct.

ESCMID Online Lecture Library

ESCMID Online Lecture Library History of phleboviruses in Greece July-August 1941. 20% of German troops in Athens district and islands had sandfly fever. 1945. SF cases among British troops in Ellinikon area (suburb of Athens near the sea). 1948. SF cases among Germans in Ellinikon area . 1946. Application of DDT. Sandfly fever very rare. 1981. Rodhain et al., Isolation of a SFSV-like virus (Corfou Pa Ar 814) from Phlebotomus major in Corfu island. Seroprevalence : Tesh and Papaevangelou, 1977 Among residents of Athens >30© years: by SFNV author 36%, SFSV 13% . < 30 years: SFNV 4%, SFSV 0%. Antoniadis et al 1990 Among healthy farmers SFNV: 16.7%, SFSV 2%, Corfu virus 4%. Papa et al. 2010 AgainstESCMID TOSV: 51.7% in Corfu,Online 39% in CephaloniaLecture Ionian Library islands Corfou virus Chios virus 2003. 21 y female admission at Chios hospital with encephalitis, coma. PCR for phlebo on CSF sample: Positive

ESCMID Online Lecture Library Uukuniemi

Chios Chios vs Cyprus -SFSV: Sicilian 34% at nt, 24.5% at aa Cyprus Rift Valley Fever Day 1

Aguacate

Punta Toro

PBLL-1

Granada

Toscana 0.1 ESCMID Online Lecture Library Day 5 … more cases Uukuniemi

Naples Granada 3/22 CSF samples from patients Toscana with CNS infection during spring-

Rift Valley summer 2003-05 positive for phleboviruses. Cyprus v.

Sicilian CSF GR72-2005, myelitis No Case Date Ag Cells Cell Protein Glucose e /mm type (mg/ml (mg/ml) 3 ) GR 44-2004, meningitis ©44 by aseptic author 18.6.0 4 440 70% 54 60 meningiti 4 lymph Chios v. s 45 aseptic 13.7.0 51 90 95% 50 57 meningiti 4 lymph GR 45-2004, meningitis s 0.1 72 myelitis 20.8.0 23 22 90 45 ESCMID Online Lecture5 Library ALBANIA Sandlfies

Lezhe Kruje

Location: Lezhe and Kruje districts Time: May - September 2005 © by author Sites: peridomestic sites, and inside chicken coops, cow barns and pigpens Method: CDC miniature light traps Sandflies pooled by sex, trapping area and date of collection ESCMID Online Lecture Library Adria virus

438 sandflies, 69.9% female. 2/12 pools phlebovirus positive. Collection dates: 27 June, 5 September 2005

D10759, Uukuniemi virus DQ862467, Arbia virus, Italy 100 Adria virus, sandflies pool 5, Albania 100 Adria virus, sandflies pool 1, Albania X56464, Rift Valley Fever virus, Egypt AY293623, Chios virus, Greece 86 EF095551, Sicilian virus, Italy 100 72 AY962268, Cyprus virus, Cyprus DQ656072, Massilia virus, France EF095548,© by Naples authorvirus, strain Poona, France FJ153281, Toscana virus, France 93 100 FJ153280, Toscana virus, Spain 88 98 FJ153279, Toscana virus, Spain ADRV vs ARBV: X68414, Toscana virus, Italy 22.9% and 6.7% 0.1 ESCMID Online Lecture Libraryat nt and aa level Adria virus is pathogenic to humans

23 Sept. 2009. D10759, UUKV 2.5-y boy admitted to a hospital in AY293623, Chios virus, Greece 100 GQ165521, Corfou virus, Greece Thessaloniki, Greece, because of a 93 GU233649, Utique virus, Tunesia first episode of febrile seizures. No 100 78 GU233647, Utique virus, Tunesia underlying disease. AY962268, SFSV, Cyprus 100 Fever (38.2˚C) and vomit while in the EF095551, SFSV, Italy DQ375430, RVFV nursery school. Sudden adherence of 100 eye gaze, peroral cyanosis, masseter X56464, RVFV DQ862467, ARBV, Italy 99 muscle spasm, tonic convulsions of the Adria-1, Albania Salehabad 100 body and extremities and involuntary Adria-5, Albania serocomplex loss of urine. The episode lasted 3 Adria-15, Greece DQ656072, Massilia virus, France minutes. He presented irritability and DQ975233, TOSV, Italy felt sleepy. By the time he entered the © by author97 FJ153281, TOSV, France 100 hospital, he was apyretic. 69FJ153280, TOSV, Spain 87 Clinical examination normal. FJ153279, TOSV, Spain GQ165522, Tehran virus, Iran leukocytosis (22.600/μl) - 85.7% GU183868, SFNV, Italy 100 neutrophils. EF095548, SFNV, France 0.1 Full recover, dischargeESCMID 2 days later Online. Lecture Library LEFKAS ISLAND July 2009 Sandflies collected using CDC light traps in animal shelters located in peridomestic areas in 3 localities of Lefkas island. Time: from dusk to dawn on 1 night per site.

ESCMID Online Lecture Library 974 sandflies grouped in 32 pools based on trapping location and date. Representative identification Phlebotomus similis 46.4% P. perfiliewi 24.8% (TOSV, ARBV) P. tobbi (perniciosus) 20.9% (TOSV, ARBV, MASV) P. neglectus (major) 7.5% (Corfu v) P. papatasi 0.4% (SFSV, SFNV)

ESCMID Online Lecture Library One pool of female sandflies collected on 7 July 2009: positive for phleboviruses. Marantohori village (110 m). 3 km from the seaside. Temperature (evening) 25oC. Olive trees, stony ground. Nearby a stable with goats. UUKV ARBV Lefkas virus 32% different SALV from SALV ADRV-human, Greece ADRV-sandflies, Albania ADRV-sandflies, Albania MASV SFNV TOSV TOSV TOSV © by author TOSV Inoculation on Vero E6 cells: RVFV CPE 5 days post inoculation Corfou virus SFSV ESCMIDCYPV Online Lecture Library 0.1 There is increasing evidence that many phleboviruses are waiting to be discovered…

ESCMID Online Lecture Library As you set out for Ithaka hope the voyage is a long one, full of adventure, full of discovery.

Quando ti metterai in viaggio per Itaca ESCMID Online Lecturedevi augurarti Library che la strada sia lunga, fertile in avventure e in esperienze.