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Clinically Important Vector-Borne Diseases of Europe

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Clinically Important Vector-Borne Diseases of Europe Natalie Cleton, DVM Erasmus MC, Rotterdam Department of Viroscience [email protected] No potential conflicts of interest to disclose Erasmus Medical Centre Department of Viroscience Laboratory Diagnosis of Arboviruses Natalie Cleton Marion Koopmans Chantal Reusken [email protected] Distribution Arboviruses with public health impact have a global and ever changing distribution Notifications of vector-borne diseases in the last 6 months on Healthmap.org Syndromes of arboviral diseases 1) Febrile syndrome: – Fever & Malaise – Headache & retro-orbital pain – Myalgia 2) Neurological syndrome: – Meningitis, encephalitis & myelitis – Convulsions & coma – Paralysis 3) Hemorrhagic syndrome: – Low platelet count, liver enlargement – Petechiae – Spontaneous or persistent bleeding – Shock 4) Arthralgia, Arthritis and Rash: – Exanthema or maculopapular rash – Polyarthralgia & polyarthritis Human arboviruses: 4 main virus families Family Genus Species examples Flaviviridae flavivirus Dengue 1-5 (DENV) West Nile virus (WNV) Yellow fever virus (YFV) Zika virus (ZIKV) Tick-borne encephalitis virus (TBEV) Togaviridae alphavirus Chikungunya virus (CHIKV) O’Nyong Nyong virus (ONNV) Mayaro virus (MAYV) Sindbis virus (SINV) Ross River virus (RRV) Barmah forest virus (BFV) Bunyaviridae nairo-, phlebo-, orthobunyavirus Crimean-Congo heamoragic fever (CCHFV) Sandfly fever virus (SFV, TOSV) Rift Valley fever virus (RVFV) Oropouche virus (OROV) 5 Reoviridae Seadorna- en coltivirus Colorado tick-borne fever (CTFV) Banna virus (BANV) 8 maart 2016 5 8 maart 2016 Overview of spread & syndromes of vector-borne diseases Many diseases display overlapping symptoms and geographical distribution Europe AR NS HS WNV* TBEV* DENV^ East Asia North America DENV^ WNV* CCHFV AR NS HS AR NS HS TAHV LIV DENV^* JEV* DENV^* WNV* CEV/LCV* DENV^ SINV* TOSV* §SFV* DENV^ WNV* WNV TBEV OHFV CHIKV BATV CHIKV* WNV SFTSV CHIKV POWV TAHV SLEV TAHV BANV CCHFV EEEV West and Central Asia TAHV WEEV AR NS HS CTFV DENV^* CHIKV* RVFV* North Africa WNV* WNV* CCHFV AR NS HS TAHV TBEV DENV^* Caribbean and Central America DENV^* TOSV* RVFV* SINV BANV OHFV South and Southeast Asia AR NS HS WNV* RVFV* CCHFV* TAHV AHFV AR NS HS DENV^ OROV* DENV^* CHIKV* TAHV YFV* §SFV* RVFV* DENV^ JEV* DENV^* * SINV DENV^* * WNV WEEV TAHV §SFV* WNV* WNV* KFDV ZIKV* EEEV BUNV ZIKV* TBEV SFTSV OROV* VEEV Sub-Saharan Africa TBEV BANV CCHFV CHIKV* ILHV AR NS HS CHIKV* TAHV WNV DENV^ WNV* DENV^* TAHV Flaviridea SLEV * WNV* RVFV* RVFV* Togaviridae South America YFV* BUNV NRIV ZIKV TAHV ILEV AR NS HS CHIKV* BWA CCHFV Bunyaviridae DENV^* OROV* DENV^* SINV BUNV ZIKV* WEEV YFV ONNV ILEV Reoviridae WNV EEEV Oceania BWA CHIKV* VEEV TAHV AR NS HS MAYV* SLEV ILEV RRV* MEV* DENV^ OROV* WNV TATV §WSBV BFV* JEV ILHV NRIV CHIKV WNV ROCV SINV WNV DENV^ ZIKV Fig 1. Geographical distribution of medically important arboviruses that cause febrile disease in humans. All arboviruses cause febrile symptoms, but symptoms more specific to certain viruses are represented in three columns: 1) Arthralgia-Rash (AR); 2) Neurological symptoms (NS), and 3) Hemorrhagic symptoms (HS). Virus name is written in the color of its corresponding (and potentially cross-reactive) family. Arboviruses not known to cause more than febrile symptoms are preceded with a §-sign. Arboviruses more likely to be diagnosed in travelers are followed by *. AKHV = Alkhurma hemorrhagic fever virus; BANV = Banna virus; BFV = Barmah Forest virus; BWAV = Bwamba virus; BUNV = Bunyamwera virus; CEV = California encephalitis virus; CHIKV = Chikungunya virus; CTFV = Colorado tick fever virus; CCHFV = Crimean-Congo hemorrhagic fever; DENV = Dengue virus; EEEV = Eastern equine encephalitis virus; GROV = Guaroa virus; ILEV = Ilesha virus; ILHV = Ilheus virus; JEV = Japanese encephalitis virus; KFDV = Kyasanur Forest disease virus; LCV = La cross virus; LIV = Louping Ill virus; MAYV = Mayaro virus; MURV = Murray Valley virus; NRIV = Ngari virus; OHFV = Omsk hemorrhagic fever virus; ONNV = O’Nyong Nyong virus; OROV = Oropouche virus; RVFV = Rift Valley fever virus; ROCV = Rocio virus; RRV = Ross river virus; SFV = Sandfly fever (Naples / Sicilian / other); SFTS V = Severe Fever with Thrombocytopenia Syndrome Virus; SINV = Sindbis virus; SLEV = St. Louis encephalitis virus; TAHV = Tahyna virus; TATV = Tataguine virus; TBEV = Tick-borne encephalitis virus; TOSV = Toscana virus; VEEV = Venezuelan equine encephalitis virus; WEEV = Western equine encephalitis virus; WNV = West Nile virus; YFV = Yellow fever virus; ZIKV = Zika virus. Cleton et al 2012 Journal of Clinical virology & Cleton et al 2015 PNTD Testing algorithm Section based on - Travel history - Clinical symptoms - Potential cross-reactivity / vaccination - Virus kinetics (Days post onset symptoms) ---------------------------------------- - Exposure history - Risk factors Testing algorithm and Information provided Information provided to LIMS Travel history 75% General symptoms 42% ? Vaccination history 0.5% Days post onset 0.5% Sample possibilities - Serum / plasma => Virus detection / Antibodies - CSF => Virus detection / Antibodies - Urine (WNV, DENV, ZIKV) => Virus detection - Tissues (post mortem) => Virus detection Cleton et al, Clinical Virology, 2012 Testing method options Viral detection • Virus isolation => Vero cells => BSL3/4!!!! • Detection of viral genome => RT-PCR / IHC • Detection of viral antigen => DENV NS1 1 8 maart 2016 0 Testing method options Antibody detection • IgG/IgM - Seroconversion - IgG/IgM 4x titer increase =>2 samples needed with 14 day interval - IgM in liquor in case of neurological disease => confirmative - IgG saliva (experimental) ELISA Immuno flourenscence Plaque reduction Neutrilization Haemagglutination inhibition 1 8 maart 2016 1 Test selection dependent on disease kinetics Humans are often dead-end hosts in these cases • West Nile virus • Japanese encephalitis virus • Tick-borne encephalitis virus • Sandfly fever virus Onset of NS symptoms L. Peterson, proceedings on Arboviral Management 2012 WNV, TBEV, TOSV sensitivity type of tests Sensitivity Molecular Serology 0-3 days POS Fever => 56% in serum Fever => 54% in serum NS => 10% serum / 55% CSF NS => 75% serum/CSF 4-7 days POS Fever => 10% in serum Fever => 98% in serum NS => 10% serum / 55% CSF NS => 100% serum/CSF >7 days POS Fever => 4% in serum Fever => 98% in serum NS => 1% serum / 10% CSF NS => 100% serum/CSF Urine: +/- 14 days POS RT-PCR pos POS = Post Onset Symptoms NS = Neurological symptoms Disease kinetics CHIKV, ZIKV, DENV Day 1-2 Onset of NS symptoms Guzman, M. G. et al. Nature Reviews Microbiology 8, S7–S16 (2010). DENV, (ZIKV), CHIKV sensitivity type of tests Sensitivity Molecular Serology 0-3 days POS Fever => 50% in serum Fever => 50% in serum 4-7 days POS Fever => 50% in serum Fever => 75-100% in serum >7 days POS Fever => <10% in serum Fever => 100% in serum DENV NS1-antigen-capture: 2-9 days POS (primary) or 1-4 days POS (secondary) • not replacement for PCR! • low sensitivity….. • cross-reactivity…..(minimal) • Aspecific reactions (snap-test) POS = Post Onset Symptoms NS = Neurological symptoms Disease kinetics CCHFV Ergonul, LID 2006 CCHFV sensitivity type of tests Virus isolation Molecular Serology 0-3 days POS 67% serum 0% serum 4-7 days POS 71% serum 65% serum >7 days POS 61% serum up to 98% serum 16 days POS POS = Post Onset Symptoms Interpretation of serological results Results dependent Health status of patient • Vaccination history: Cross-reactivity in serological tests due to flavivirus vaccines • Yellow fever virus (South Americas, Africa) • Japanese encephalitis virus (Asia) • Tick-brone encephalitis virus (Central and Eastern Europe) • Dengue virus (Central and South Americas) • YOPI’s => low or no immune response (extended viremia or IgM response) • Previous infections => antigenic sin • Cross-reactivity & sensitivity differ dependent on viral antigen used (or whole virus used) => in-house validation essential for interpretation! 18 1 8 maart 2016 8 Antigenic sin Memory B-cells developed against epitopes of primary pathogen Secondary infection with closely related pathogen (Influenza, Dengue, HIV, Cowpox) Memory B-cells activated to primary pathogen Reducing production of b-cells to secondary pathogen http://nfs.unipv.it/nfs/minf/dispense/immunology/lectures Interpretation of arbovirus diagnostic results Acute sample Antigen- Virus IgM IgG PCR capture isolation Pos Pos Pos Pos Neg Neg Pos Neg No Vaccination Neg in CSF? history? IHC Pos Yes No Neg Pos interpretatio interpretatio interpretatio ID Virus n not n not ID Virus n not possible possible possible Convalescent serum sample with 2wk interval needed Seroconversion or 4-fold titre increase (VNT) Pos Neg ID Virus No diagnosis Interpretation of results dependent on test specifics Sensitivity / Specificity provided by manufacturer ● Analytical sens/sepc dependent on: - cross-reactivity - lab variation - robustness test - a-specific reactions (Malaria in snap-tests) ● Diagnostic sens/sepc dependent on: - Sampling day post onset disease => viral kinetics - Comparison method used (how solid is the Gold Standard?) - Background of validation samples used (predictive value): Endemic / sporadic / disease free area Healthy / disease population Vaccination status / previous exposure Important terms in interpretation of (all!) diagnostic tests Bayesian Clinical Diagnostic Model True presence of disease Total positive for Total negative for Total population disease (a+c) disease (b+d) Positive predictive value Predicted positive True positive
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