West Nile virus (WNV) was first detected in the Western Hemisphere in 1999 during
an outbreak of encephalitis in New York City. Over the next 5 years, the virus spread
across the continental United States as well as north into Canada, and southward into
the Caribbean Islands and Latin America (1). This article highlights new information
about the epidemiology and transmission dynamics of human WNV disease obtained over
the past 5 years of intensified research.
Epidemiology
WNV is transmitted primarily by the bite of infected mosquitoes that acquire the virus
by feeding on infected birds. The intensity of transmission to humans is dependent
on abundance and feeding patterns of infected mosquitoes and on local ecology and
behavior that influence human exposure to mosquitoes. Although up to 55% of affected
populations became infected during epidemics in Africa, more recent outbreaks in Europe
and North America have yielded much lower attack rates (1,2). In the area of most
intense WNV transmission in Queens, New York, in 1999, ≈2.6% of residents were infected
(most of these were asymptomatic infections), and similarly low prevalence of infection
has been seen in other areas of the United States (3,4). WNV outbreaks in Europe and
the Middle East since 1995 appear to have caused infection in <5% of affected populations
(1,5). These levels of infection are too low to decrease the frequency of epidemics
or modulate their intensity through protective immunity.
Data on the incidence of WNV in most of the world are not readily available. WNV transmission
has been reported in Europe, the Middle East, Africa, India, parts of Asia, Australia
(in the form of Kunjin virus, a subtype of WNV), North America, and parts of Central
America and the Caribbean (1,6). In recent years human WNV disease in the Eastern
Hemisphere has been reported mostly from areas in the Mediterranean Basin: in Algeria
in 1994, Morocco in 1996, Tunisia in 1997 and 2003, Romania in 1996 through 2000,
the Czech Republic in 1997, Israel in 1999 and 2000, Russia in 1999 through 2001,
and France in 2003 (1,6,7). Enzootics involving horses were reported in Morocco in
1996 and 2003, Italy in 1998, Israel in 2000, and southern France in 2000, 2003, and
2004 (6–8).
In the Western Hemisphere, most human WNV disease has occurred in the United States.
Since the virus was detected in New York from 1999 through 2004, 16,706 cases have
been reported to the Centers for Disease Control and Prevention (CDC); 7,096 of these
were classified as neuroinvasive disease, 9,268 as West Nile fever (WNF), and 342
had other or unspecified clinical presentation (reported through June 8, 2005; the
proportion of total cases reported that are neuroinvasive disease is artificially
higher than what is believed to occur naturally since neuroinvasive disease is more
likely to be reported than WNF or asymptomatic infection) (Table 1). Transmission
of WNV has spread dramatically from New York to the north, south, and west (Figure
1). From 2002 to 2003, the most intense transmission shifted from the Midwest and
south-central states to the western plains and Front Range of the Rocky Mountains.
In 2004, most WNV disease cases were reported in California, Arizona, and western
Colorado, but foci of highest incidence were scattered across the United States (Figure
1). In the East, WNV transmission recurred for 6 consecutive years with the highest
number of human disease cases reported in 2003, indicating that WNV disease has become
seasonally endemic. In Canada, transmission of WNV to humans has been documented in
Quebec, Ontario, Manitoba, Saskatchewan, and Alberta, and WNV-infected birds have
also been found in New Brunswick and Nova Scotia (http://www.phac-aspc.gc.ca/wnv-vwn).
Evidence of WNV transmission has been reported from the Cayman Islands, Jamaica, Dominican
Republic, Mexico, Guadeloupe, El Salvador, Belize, Puerto Rico, and Cuba, but only
1 human case has been reported from Mexico and 1 from the Cayman Islands (http://www.paho.org/English/DD/PIN/ptoday15_oct03.htm;
http://www.paho.org/English/AD/DPC/CD/wnv.htm; http://www.cenave.gob.mx/von/default.asp;
http://www.serc.si.edu/labs/avian/wnv.jsp) (1). The paucity of human cases thus far
in Latin America and the Caribbean is surprising, considering the ecologic conditions
that favor arbovirus transmission in these areas. WNV isolated from a bird in Mexico
in 2003 appeared to be attenuated, but whether viral mutation accounts for the scarcity
of human disease remains to be seen (9).
Table 1
Human West Nile virus disease cases by clinical syndrome, United States, 1999–2004*
Year
Total cases
Neuroinvasive cases
West Nile fever cases
Other clinical /unspecified
Deaths
1999
62
59
3
0
7
2000
21
19
2
0
2
2001
66
64
2
0
9
2002
4,156
2,946
1,162
48
284
2003
9,862
2,866
6,830
166
264
2004*
2,539
1,142
1,269
128
100
Total
16,706
7,096
9,268
342
666
*Reported to the Centers for Disease Control and Prevention as of June 8, 2005.
Figure 1
Reported incidence of neuroinvasive West Nile virus disease by county, United States,
1999–2004. Reported to Centers for Disease Control and Prevention by states through
April 21, 2005.
The incidence of WNV disease is seasonal in the temperate zones of North America,
Europe, and the Mediterranean Basin, with peak activity from July through October
(6,10). In the United States, the transmission season has lengthened as the virus
has moved south; in 2003, onset of human illness began as late as December, and in
2004 as early as April (CDC, unpub. data). Transmission of WNV in southern Africa
and of Kunjin virus in Australia increases in the early months of the year after heavy
spring and summer rainfall (2,11).
In the United States, persons of all ages appear to be equally susceptible to WNV
infection, but the incidence of neuroinvasive WNV disease and death increases with
age, especially among those 60 to 89 years of age, and is slightly higher among male
patients (Figure 2) (10). During 2002, the median age among neuroinvasive disease
cases was 64 years (range 1 month to 99 years), compared to a median age of 49 years
(range 1–97 years) for WNF cases (10). Of the 2,942 neuroinvasive disease cases, 276
(9%) were fatal (10). Although severe disease occurs primarily in adults, neuroinvasive
disease in children has been reported. From 2002 through 2004, 1,051 WNV disease cases
among children <19 years of age were reported in the United States; 317 (30%) had
neuroinvasive disease; and 106 (34%) of these were <10 years (CDC, unpub. data; reported
through June 8, 2005). Two (0.6%) pediatric patients with neuroinvasive WNV disease
died: an infant with underlying lissencephaly and a 14-year-old boy with immune dysfunction.
Figure 2
Reported incidence of neuroinvasive West Nile virus disease by age group and sex,
United States, 1999–2004. Reported to the Centers for Disease Control and Prevention
by states through April 14, 2005.
The most important risk factor for acquiring WNV infection is exposure to infected
mosquitoes. In Romania the risk for WNV infection was higher among persons with mosquitoes
in their homes and with flooded basements (12). An analysis of the locations of WNV
disease cases during the 1999 outbreak in New York found that cases were clustered
in an area with higher vegetation cover, indicating favorable mosquito habitat (13).
A study of the outbreak in Chicago in 2002 indicated that human disease cases tended
to occur in areas with more vegetation, older housing, lower population density, predominance
of older Caucasian residents, and proximity to dead birds, but the effects of these
variables were influenced by differences in mosquito abatement efforts (14). Risk
factors for infection not related to mosquito exposure include receiving blood transfusions
or organ donations, maternal infection during pregnancy or breastfeeding, and occupational
exposure to the virus (15–17).
Apart from older age and immunosuppression after organ transplantation, the risk factors
for the development of severe neuroinvasive WNV disease have yet to be determined
(10,16). Underlying hypertension, cerebrovascular disease, and diabetes have been
considered as possible predisposing factors; further study may elucidate the role
of these or other host factors that might modify the risk for severe disease or death
(12). Genetic predisposition for severe disease has been described in mice but has
not yet been elucidated in humans (18). The role of innate and adaptive immune responses
in determining outcome deserves further study.
Nonmosquitoborne WNV Transmission
In 2002, intrauterine WNV transmission was documented for the first time (15). A 20-year-old
woman had onset of WNV disease in week 27 of gestation. Her infant was born at term
with chorioretinitis and cystic damage of cerebral tissue. Intensified surveillance
identified 4 other mothers who had WNV illness during pregnancy, 3 of whom delivered
infants with no evidence of WNV infection; all 3 infants appeared normal at birth
and at 6 months of age (15). The fourth woman delivered prematurely; her infant had
neonatal respiratory distress but was not tested for WNV infection. In 2003, CDC received
reports of 74 women infected with WNV during pregnancy; most of these women followed
up to date have delivered apparently healthy infants (CDC, unpub. data).
Probable WNV transmission through breast milk was also reported in 2002 (15). A 40-year-old
woman acquired WNV infection from blood transfused shortly after she delivered a healthy
infant. WNV nucleic acid was detected in her breast milk, and immunoglobulin (Ig)
M antibody was found in her infant, who remained healthy. No other instances of possible
WNV transmission through breast milk have been reported. Until more data are available,
and because the benefits of breastfeeding are well documented, mothers should be encouraged
to breastfeed even in areas of ongoing WNV transmission.
Transmission of WNV through blood transfusion was first documented during the 2002
WNV epidemic in North America (15). In June 2003, blood collection agencies in the
United States and Canada enhanced donor deferral and began screening blood donations
with experimental nucleic acid amplification tests. During 2003 and 2004, >1,000 potentially
WNV-viremic blood donations were identified, and the corresponding blood components
were sequestered. Nevertheless, 6 WNV cases due to transfusion were documented in
2003, and at least 1 was documented in 2004, indicating that infectious blood components
with low concentrations of WNV may escape current screening tests (19). One instance
of possible WNV transmission through dialysis has been reported (20).
WNV transmission through organ transplantation was also first described during the
2002 epidemic (15). Chronically immunosuppressed organ transplant patients appear
to have an increased risk for severe WNV disease, even after mosquito-acquired infection
(16). During 2002, the estimated risk of neuroinvasive WNV disease in solid organ
transplant patients in Toronto, Canada, was approximately 40 times greater than in
the general population (16). Whether other immunosuppressed or immunocompromised patients
are at increased risk for severe WNV disease is uncertain, but severe WNV disease
has been described among immunocompromised patients.
WNV infection has been occupationally acquired by laboratory workers through percutaneous
inoculation and possibly through aerosol exposure (21,22). An outbreak of WNV disease
among turkey handlers at a turkey farm raised the possibility of aerosol exposure
(17).
Dynamics of Transmission: Vectors
WNV is transmitted primarily by Culex mosquitoes, but other genera may also be vectors
(23). In Europe and Africa, the principal vectors are Cx. pipiens, Cx. univittatus,
and Cx. antennatus, and in India, species of the Cx. vishnui complex (6,24). In Australia,
Kunjin virus is transmitted primarily by Cx. annulirostris (11). In North America,
WNV has been found in 59 different mosquito species with diverse ecology and behavior;
however, <10 of these are considered to be principal WNV vectors (CDC, unpub. data)
(23,25,26). In 2001, 57% of the positive mosquito pools in the Northeast were Cx.
pipiens, the northern house mosquito, a moderately efficient vector that feeds on
birds and mammals (Table 2). In 2002, Cx. pipiens made up more than half of the WNV-positive
pools, but Cx. quinquefasciatus, the southern house mosquito, generally considered
a moderate- to low-efficiency vector, appeared to be the predominant vector in the
South. Cx. tarsalis, 1 of the most efficient WNV vectors evaluated in laboratory studies,
was the predominant vector west of the Mississippi River (CDC, unpub. data) (26).
Table 2
West Nile virus (WNV)–positive mosquito pools, by species, United States, 2001–2004*
2001
2002
2003
2004 (through 11/30/2004)
Positive pools, n = 612†
Positive pools, n = 3,720†
Positive pools, n = 5,538†
Positive pools, n = 4,755†
Species
% of pools
Species
% of pools
Species
% of pools
Species
% of pools
Culex pipiens
57.0
Cx. pipiens
47.0
Cx. tarsalis
31.5
Cx. quinquefasciatus
51.4
Cx. restuans
12.4
Cx. quinquefasciatus
19.1
Cx. pipiens
20.8
Cx. tarsalis
20.4
Cx. salinarius
11.4
Cx. restuans
9.1
Cx. quinquefasciatus
19.1
Cx. pipiens
12.7
Culiseta melanura
4.2
Cx. tarsalis
7.6
Cx. restuans
15.3
Cx. restuans
4.4
Cx. quinquefasciatus
2.1
Cx. salinarius
3.6
Cx. salinarius
4.5
Cx. erythrothorax
3.6
Ochlerotatus. triseriatus
2.1
Aedes albopictus
2.0
Ae. vexans
2.3
21 other species‡
10.6
23 other species‡
11.5
35 other species‡
6.4
35 other species‡
7.5
*Data were derived from reports submitted by state health departments to the Centers
for Disease Control and Prevention's Arbonet surveillance system. Mosquito specimens
were collected, identified, and tested in the respective state surveillance systems.
Pools were reported as positive if they contained detectable levels of one of the
following: infectious WNV, WNV RNA, WN viral antigen.
†Includes only WNV-positive
pools reported as monospecific, i.e., excludes mixed pools (e.g., Cx. pipiens/restuans)
or pools identified only to genus (e.g., Culex species).
‡No other species individually
comprised ≥2.0% of the WNV-positive pools.
During 2003, as WNV activity progressed westward, Cx. tarsalis became the most commonly
reported WNV-positive mosquito species, making up 32% of the positive pools reported,
followed by Cx. pipiens, Cx. quinquefasciatus, and Cx. restuans (Table 2). Cx. salinarius
and Cx. nigripalpus may be important vectors in areas where they are abundant (26).
During 2004, when large epidemics occurred in the southwestern United States, the
most commonly reported WNV-positive species was Cx. quinquefasciatus, which made up
over half of the positive pools, followed by Cx. tarsalis and Cx. pipiens (Table 2).
The intensity of WNV transmission is determined primarily by the abundance of competent
mosquitoes and the prevalence of infection in mosquitoes. The estimated prevalence
of infection, measured as the minimum infection rate (MIR), that is needed to produce
epidemics is uncertain. Toward the end of the 1999 New York epidemic, the WNV MIR
for all Culex mosquitoes sampled in the area was 0.3% with MIRs of individual collections,
ranging from 0.07% to 5.7% (27). During the 2000 Staten Island epidemic, the MIRs
in mixed Cx. pipiens/restuans pools ranged from 0.5% to 1.6% and the MIR in Cx. salinarius
from 0.3% to 1.2% (28). Relatively low MIRs in Cx. restuans (0.2%), Cx. pipiens (0.1%)
and Cx. salinarius (0.1%) in Connecticut during 2000 were associated with an intense
epizootic, but apparently a low risk for humans (29). In 2001, moderate to high MIRs
in Cx. quinquefasciatus (0.5%) and Cx. nigripalpus (1.1%) were associated with epizootic
and epidemic transmission in Florida (30). In some North American outbreaks, MIRs
as high as 15% have been observed (CDC, unpub. data). Vertical transmission of WNV
has been experimentally demonstrated in Cx. pipiens, Cx. quinquefasciatus, and Cx.
tarsalis, and the virus has been isolated from hibernating female mosquitoes, which
may provide a mechanism for persistence of the virus in colder latitudes through the
winter and reemergence of transmission in the spring (31,32).
Although both soft and hard ticks can become infected with WNV, they are unlikely
to play a substantial role in WNV transmission. In the laboratory, Argas arboreus
ticks transmitted WNV to chickens, and Ornithodoros savignyi, O. maritimus, O. erraticus,
and O. moubata transmitted WNV to mice (33). However, of the hard ticks Amblyomma
americanum, Ixodes scapularis, I. ricinus, Dermacentor variabilis, and D. andersoni,
the last 4 species became infected with WNV, but none transmitted the virus by subsequent
bite (33,34).
Dynamics of Transmission: Vertebrate Hosts
Laboratory studies have demonstrated that 74%–100% of Cx. tarsalis mosquitoes become
infected after consuming blood meals with WNV concentrations of 107.1 plaque-forming
units (PFU)/mL, while only 0%–36% become infected after consuming a meal containing
104.9 PFU/mL (35). The maximum estimated concentration of WNV in human blood tested
during screening of blood donors in 2002 was approximately 103.2 PFU/mL (S. Stramer,
M. Busch, M. Strong, pers. comm.). Thus, it appears unlikely that humans exhibit WNV
viremia levels of sufficient magnitude to infect mosquitoes.
Birds are presumed to be the most important amplifying hosts of WNV. In laboratory
studies, species in the orders Passeriformes (song birds), Charadriiformes (shorebirds),
Strigiformes (owls), and Falconiformes (hawks) developed viremia levels sufficient
to infect most feeding mosquitoes, whereas species of Columbiformes (pigeons), Piciformes
(woodpeckers), and Anseriformes (ducks) did not (23,36). Certain passerines, including
common grackles (Quiscalus quiscula), various corvids (crows, jays, magpies), house
finches (Carpodacus mexicanus), and house sparrows (Passer domesticus) were highly
infectious to mosquitoes and had mortality rates >40%. Field studies during and after
WNV outbreaks in several areas of the United States have confirmed that house sparrows
were abundant and frequently infected with WNV, characteristics that would allow them
to serve as important amplifying hosts (23,25,37). The importance of birds in dispersing
WNV remains speculative. Local movements of resident, nonmigratory birds and long-range
travel of migratory birds may both contribute to the spread of WNV (38,39).
Although WNV was isolated from rodents in Nigeria and a bat in India, most mammals
do not appear to generate viremia levels of sufficient titer to contribute to transmission
(24,40–42). Three reptilian and 1 amphibian species (red-ear slider, garter snake,
green iguana, and North American bullfrog) were found to be incompetent as amplifying
hosts of a North American WNV strain, and no signs of illness developed in these animals
(43). Viremia levels of sufficient titer to infect mosquitoes were found after experimental
infection of young alligators (Alligator mississippiensis) (44). In Russia, the lake
frog (Rana ridibunda) appears to be a competent reservoir (45).
Nonmosquitoborne WNV transmission has been observed or strongly suspected among farmed
alligators, domestic turkeys in Wisconsin, and domestic geese in Canada (17,46,47).
Transmission through close contact has been confirmed in both birds and alligators
in laboratory conditions but has yet to be documented in wild vertebrate populations
(23,36,44).
Control of WNV Transmission
Avoiding human exposure to WNV-infected mosquitoes remains the cornerstone for preventing
WNV disease. Source reduction, application of larvicides, and targeted spraying of
pesticides to kill adult mosquitoes can reduce the abundance of mosquitoes, but demonstrating
their impact on the incidence of human WNV disease is challenging because of the difficulty
in accounting for all determinants of mosquito abundance and human exposure. One study
indicated that clustering of human WNV disease in Chicago varied between mosquito
abatement districts, suggesting that mosquito control may have some impact on transmission
to humans (14).
Persons in WNV-endemic areas should wear insect repellent on skin and clothes when
exposed to mosquitoes and avoid being outdoors during dusk to dawn when mosquito vectors
of WNV are abundant. Of insect repellents recommended for use on skin, those containing
N,N-diethyl-m-toluamide (DEET), picaridin (KBR-3023), or oil of lemon eucalyptus (p-menthane-3,8
diol) provide long-lasting protection (48). Both DEET and permethrin provide effective
protection against mosquitoes when applied to clothing. Persons' willingness to use
DEET as a repellent appears to be influenced primarily by their level of concern about
being bitten by mosquitoes and by their concern that DEET may be harmful to health,
despite its good safety record (49).
To prevent transmission of WNV through blood transfusion, blood donations in WNV-endemic
areas should be screened by using nucleic acid amplification tests. Screening of organ
donors for WNV infection has not been universally implemented because of concern about
rejecting essential organs after false-positive screening results (50). Pregnant women
should avoid exposure to mosquito bites to reduce the risk for intrauterine WNV transmission.
Future Directions
WNV disease will likely continue to be a public health concern for the foreseeable
future; the virus has become established in a broad range of ecologic settings and
is transmitted by a relatively large number of mosquito species. WNV will also likely
continue to spread into Central and South America, but the public health implications
of this spread remain uncertain. Observations thus far in North America indicate that
circulation of other flaviviruses, such as dengue, viral mutation, and differing ecologic
conditions may yield different clinical manifestations and transmission dynamics.
Over the next few years, research efforts might well be focused in several areas.
Research into new methods to reduce human exposure to mosquitoes is crucial and can
help prevent other mosquitoborne illnesses. This should include development of new
methods to reduce mosquito abundance, development of new repellents, and behavioral
research to enhance the use of existing effective repellents and other personal protective
measures against mosquito bites. A better understanding of the dynamics of nonmosquitoborne
transmission is essential to prevent disease among infants of infected mothers and
recipients of blood transfusions and transplanted organs. Currently available prevention
strategies such as the dissemination of knowledge and products for personal protection
from mosquito exposure and the application of existing techniques for reducing mosquito
abundance in communities at risk of WNV transmission need to be vigorously implemented.
National and international surveillance for WNV transmission will be important to
monitor spread of the virus and the effect of control strategies. Finally, further
research into the ecologic determinants of WNV transmission, including climatic factors
and dynamics of reservoir and vector populations, could help in determining geographic
areas of higher risk for WNV disease.