Roger S' Nasci, Ph'D'

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WNV National Conference Ten Years
Later AMCA-CDC, February 19-20, 2009 Savannah,
GA
10 years of WNV in the U.S. A Historical
Perspective
Roger S. Nasci, Ph.D. Arboviral Diseases
Branch Division of Vector-Borne Infectious
Diseases Centers for Disease Control and
Prevention
The findings and conclusions in this presentation
are those of the authors and do not necessarily
represent the views of the Centers for Disease
Control and Prevention
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West Nile virus was first isolated in 1937 from
the blood of a febrile woman in the West Nile
province of Uganda.
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Smithburn JS, Hughes TP, Burke AW, Paul JH. A
neurotropic virus isolated from the blood of a
native of Uganda. Am J Trop Med Hyg.
19402047192.
Medical Department of the Uganda
Protectorate International Health Division of The
Rockefeller Foundation.
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West Nile Virus Epidemics

• First recorded epidemic in Israel in 1950s.
• Israel 1951-1954, 1957
• France 1962
• South Africa 1974
• Romania 1996
• Italy 1998

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West Nile Virus Approximate Geographic Range in
1998
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the United States has no comprehensive national
system for detecting outbreaks of infectious
disease. Outbreaks of any disease that is not on
CDC's current list of notifiable illnesses may go
undetected or may be detected only after an
outbreak is well under way.
Although many local and regional vector-control
programs can effectively combat small and even
medium-size outbreaks of vector-borne disease,
they are not equipped to deal with outbreaks that
are national in scope.
The significance of zoonoses in the emergence of
human infections cannot be overstated.
Emerging Infections Microbial Threats to Health
in the United States. Joshua Lederberg, Robert
E. Shope, and Stanley C.Oaks, Jr., Editors
Committee on Emerging Microbial Threats to
Health, Institute of Medicine (1992)
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West Nile Virus In New York - 1999
NYC - 1795 Yellow Fever Outbreak 730 Deaths
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Epizootic
Epizootic and Epidemic investigations Initially
separate events that eventually converged.
Summarized from West Nile Virus Outbreak
Lessons for Public Health Preparedness.
GAO/HEHS-00-180. September 2000
Epidemic
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Epizootic

• Reports of dead birds (crows)
• Veterinarian (Bayside) finds crows with signs of
  nervous system disorders, treats and releases
  survivors.

Epidemic
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Epizootic

• Bronx Zoo, Wildlife Conservation Society, Nassau
  County send birds to NYS-DEC.
• Bronx zoo birds die.

• 8/2 First human infection (retrospective).
• 8/12 First case admitted to Flushing hospital.
• 8/23 5th case admitted, Hospital contacts
  NYC-DOH.
• 8/31 Samples arrive at NYS-DOH lab.

Epidemic
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Epizootic

• NYS-DEC and Bronx Zoo send bird samples to
  USGS-NWHC and to USDA-NVSL, virus isolated,
  unidentified.
• Conn Ag Exp Stn isolates virus from crow brain.
• NVSL isolates sent to CDC.

• 9/1 NYS-DOH lab reports Flavivirus positive
  serology SLE?
• 9/3 CDC lab confirms SLE, NYC starts vector
  control.
• Autopsy samples to UC Irvine encephalitis
  project.

Epidemic
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Epizootic
Epidemic

• Isolates identified as Flavivirus by CDC, UC
  Irvine.
• Partial sequence analysis interpreted as
  WNV-like, Kunjin.
• Repeat serology on humans indicates antibody
  against WNV.
• Complete sequence identifies West Nile virus from
  birds/humans.
• WNV identified from mosquitoes collected in NYC.

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Lanciotti et al. 1999. Origin of the West Nile
virus responsible for an outbreak of encephalitis
in the northeastern U.S. Science 2862333-337.
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Epizootic
Epidemic

• Equine outbreak on Long Island reported.
• WNV-positive dead crow found in Baltimore.
• November first national WNV conference.
• Jan-Feb 2000, WNV found in overwintering Cx.
  pipiens collected in NYC.

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I love the smell of malathion in the morning
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Buzz City by Barry Blitt
The New Yorker Sept. 27, 2000
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Where Are They Now?

• Deborah Asnis, M.D.
• Infectious Disease Medicine, Internal Medicine,
  Flushing Hospital Medical Center
• Marcelle Layton, M.D.
• Assistant Commissioner, Bureau of Communicable
  Disease, New York City Department of Health and
  Mental Hygiene
• Annie Fine, M.D.
• Medical Director, Zoonotic, Influenza and
  Vector-borne Disease Unit, Bureau of Communicable
  Disease, New York City Department of Health and
  Mental Hygiene
• Farzad Mostashari, M.D.
• Assistant Commissioner, Primary Care Information
  Project , New York City Department of Health and
  Mental Hygiene.  
• Neal Cohen, M.D.
• Distinguished Lecturer, CUNY- Hunter College
• Jerry Hauer
• The Hauer Group, a Virginia-based emergency
  preparedness consultancy
• Rudy Giuliani

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Where Are They Now?

• Tracy McNamara, DVM
• Professor of Pathology, Western University of
  Health Sciences.
• Ian Lipkin, M.D.
• Professor, Department of Epidemiology, Columbia
  University Mailman School of Public Health
• Duane Gubler, Sc.D.
• Director, Program on Emerging Infectious
  Diseases, Duke University
• Director, Asia-Pacific Institute Tropical
  Medicine and Infectious Diseases
• Stephen Ostroff, M.D.
• Director, Bureau of Epidemiology, Pennsylvania
  Department of Health

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1999
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The Bite of Spring by Peter de Seve
The New Yorker April 17, 2000
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2000
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2001
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2002
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2003
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2004
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2005
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2006
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2007
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2008
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West Nile Virus Neuroinvasive Disease Cases in
United States (by year)
(As of 11/18/2008)
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West Nile Virus Activity 1999-2008
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Reported WNND Cases and WNV Deaths in
Humans,United States, 1999-2008
WNV Widespread and Pervasive in
Environment Produced Widespread and Pervasive
Impact
Reported as of 11/04/2008
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West Nile Virus-----Just another Exotic -
Invasive Species

• Any species capable of propagating, that is not
  native to that ecosystem and whose introduction
  does or is likely to cause economic or
  environmental harm or harm to human health.

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Partial list of Exotic - Invasive Species in the
United States
Pathogens Avipoxvirus (Fowlpox) Cryphonectria
parasitica (Chestnut blight) Flavivirus (West
Nile virus) Myxobolus cerebralis (Whirling
disease) Ophiostoma ulmi (Dutch elm disease)
Paramyxovirus (Exotic Newcastle disease)
Phakopsora spp. (Soybean rust) Phytophthora
ramorum (Sudden oak death) Potyvirus (Plum pox)
Others Didymosphenia geminata (Didymo, rock
snot) Lumbricidae spp. (Earthworms) Varroa
destructor (Varroa mite)
Plants Dioscorea bulbifera (Air potato) Lonicera
maackii (Amur honeysuckle) Casuarina
equisetifolia (Australian pine) Elaeagnus
umbellata (Autumn olive) Rubus armeniacus
(Blackberry) Schinus terebinthifolius (Brazilian
pepper tree) Egeria densa (Brazilian waterweed)
Caulerpa taxifolia (Caulerpa, Mediterranean
clone) Cinnamomum camphora (Camphor laurel)
Melia azedarach) (Chinaberry) Ligustrum sinense
(Chinese privet) Sapium sebiferum (Chinese
tallow) Imperata cylindrica (Cogon grass)
Cytisus scoparius (Common broom) Phragmites
australis (Common reeds) Cosmos sulphureus
Onopordum acanthium (Cotton thistle) Ardisia
crenata (Coral ardisia) Potamogeton crispus
(Curly-leaf pondweed) Centaurea diffusa (Diffuse
knapweed) Cynanchum rossicum (Dog-strangling
vine) Cynanchum louisae Bromus tectorum (Downy
brome, cheatgrass) English ivy (Hedera helix)
Eurasian watermilfoil (Myriophyllum spicatum)
Flowering rush (Butomus umbellatus) Garlic
mustard (Alliaria petiolata) Giant hogweed
(Heracleum mantegazzianum) Giant reed (Arundo
donax) Giant salvinia (Salvinia molesta)
Hydrilla (Hydrilla verticillata) Japanese
honeysuckle (Lonicera japonica) Japanese
knotweed (Polygonum cuspidatum) Japanese
climbing fern (Lygodium japonicum) Kudzu
(Pueraria montana var. lobata) Leafy spurge
(Euphorbia esula) Melaleuca (Melaleuca
quinquenervia) Mile-a-minute weed (Polygonum
perfoliatum) Mimosa (Mimosa pudica) Multiflora
rose (Rosa multiflora) Musk thistle (Carduus
nutans) Natal grass (Rhynchelytrum repens) Old
World climbing fern (Lygodium microphyllum)
Orange Hawkweed (Hieracium aurantiacum) Pampas
Grass (Cortaderia selloana) Phragmites
(Phragmites australis) Purple loosestrife
(Lythrum salicaria) Russian knapweed (Acroptilon
repens) Russian Olive (Elaeagnus angustifolia)
Saltcedar (Tamarix spp.) Scotch Broom (Cytisus
scoparius) Silk Tree (Albizia julibrissin)
Skunk vine (Paederia foetida) Smooth Cordgrass
(Spartina alterniflora Spotted knapweed
(Centaurea) Torpedo grass (Panicum repens) Tree
of heaven (Ailanthus altissima) Tropical soda
apple (Solanum viarum) Water caltrop (Trapa
natans) Water hyacinth (Eichhornia crassipes)
Wild parsnip (Pastinaca sativa) Wild taro
(Colocasia esculenta) Witchweed (Striga
asiatica) Yellow star thistle (Centaurea
solstitialis) Insects Adelges tsugae (Hemlock
woolly adelgid) Aedes albopictus (Asian tiger
mosquito) Agrilus planipennis (Emerald ash
borer) Anoplophora glabripennis (Asian
long-horned beetle) Apis mellifera scutellata
(Africanized honeybee) Bemisia argentifolii
(Silverleaf whitefly) Cactoblastis cactorum
(Cactus moth) Coptotermes formosanus (Formosan
termite) Linepithema humile (Argentine ant)
Lymantria dispar (European gypsy moth) Popillia
japonica (Japanese beetle) Solenopsis invicta
(Red imported fire ant) Aquatic
arthropods Bythotrephes cederstroemi (Spiny water
flea) Carcinus maenas (European green crab)
Eriocheir sinensis (Chinese mitten crab)
Aquatic mollusks Ampullariidae (Apple snails)
Bithynia tentaculata (Faucet snail)
Cipangopaludina chinensis (Chinese mystery
snail) Corbicula fluminea (Asian clam)
Dreissena polymorpha (Zebra mussel)
Potamopyrgus antipodarum (New Zealand mud snail)
Rapana venosa (Veined rapa whelk) Land
snails Theba pisana (White garden snail)
Fish Alosa pseudoharengus (Alewife) Channa
argus (Northern snakehead) Cyprinus carpio
(Common carp) Gymnocephalus cernuus (Eurasian
ruffe) Hypophthalmichthys molitrix (Silver carp)
Hypophthalmichthys nobilis (Bighead carp)
Monopterus albus (Asian swamp eel) Neogobius
melanostomus (Round goby) Oreochromis aureus
(Blue tilapia) Petromyzon marinus (Sea lamprey)
Pylodictis olivaris (Flathead catfish)
Reptiles and amphibians Boiga irregularis
(Brown tree snake) Bufo marinus (Cane toad)
Caiman crocodilus (Spectacled Caiman) Iguana
iguana (Green iguana) Python molurus bivittatus
(Burmese python) Rana catesbeiana (Bullfrog)
Varanus niloticus (Nile monitor) Osteopilus
septentrionalis (cuban treefrog) Birds and
mammals Columba livia (Rock pigeon) Cygnus olor
(Mute swan) Felis catus (Domestic cat)
Myocastor coypus (Coypu, nutria) Passer
domesticus (House sparrow) Sturnus vulgaris
(European starling) Sus scrofa (Wild boar)
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Yellow fever - endemic zones
WHO, 2005, 2006, 2008
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Red Imported Fire Ant
Introduced early 1900s in Mobile, Alabama
Native To South America
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Kudzu
Forest Kim Starr, U.S. Geological Survey,
Bugwood.org

• Introduced into the U.S. in 1876 at the
  Philadelphia Centennial Exposition.
• Native to Asia.
• Planted throughout the eastern United States in
  an attempt to control erosion.

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West Nile Virus - The most widespread of the
flaviviruses
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West Nile Virus National Conferences

• Fort Collins, Colorado - Nov 1999
• Charlotte, North Carolina - Jan 2001
• Atlanta, Georgia Mar 2002
• New Orleans, Louisiana Feb 2003
• Denver, Colorado Feb 2004
• San Jose, California Feb 2005
• San Francisco, California Feb 2006
• .
• .
• Savannah, Georgia Feb 2009

www.cdc.gov/ncidod/dvbid/westnile/conf/index.htm
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West Nile Virus National Conferences

• Fort Collins, Colorado - Nov 1999
• Charlotte, North Carolina - Jan 2001
• Atlanta, Georgia Mar 2002
• New Orleans, Louisiana Feb 2003
• Denver, Colorado Feb 2004
• San Jose, California Feb 2005
• San Francisco, California Feb 2006
• .
• .
• Savannah, Georgia Feb 2009

Produced WNV National Guidelines
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Guidelines for Surveillance, Prevention, and
Control of West Nile Virus Infection -- United
States

• Surveillance
• Laboratory Diagnosis
• Prevention and Control
• Public Health Infrastructure
• Interjurisdictional Data Sharing
• Research Priorities

MMWR January 21, 2000 / 49(02)25-8
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www.cdc.gov/ncidod/dvbid/westnile/resources/wnv-gu
idelines-aug-2003.pdf
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Suggested Guidelines for Phased Response to West
Nile Virus Surveillance Data
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• Established in 2000 to track WNV cases, monitor
  spread
• Capture environmental surveillance from State
  Health Departments
• Birds (dead, sentinel), Mosquitoes, Horses, other
  vertebrates
• All arboviruses of public health importance added
  in 2003
• WNV, SLE, EEE, WEE, LAC, POW
• Nationwide Comprehensive Arbovirus surveillance
  System

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http//DiseaseMaps.USGS.GOV
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ELC Program Epidemiology and Laboratory Capacity
for Infectious DiseasesCooperative Agreement

• Enhance State/Major City Public Health Laboratory
  Capacity
• 50 states, 6 cities, Puerto Rico
• Priority Program Areas
• Antimicrobial Resistance
• Foodborne Disease
• Hepatitis Prevention and Control
• Influenza
• West Nile Virus
• NEDSS
• National Electronic Disease Surveillance System

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ELC-WNV Recipient Activities

• Establish or enhance
• bird, mosquito, human and equine encephalitis
  surveillance.
• capabilities to capture, identify and test
  mosquito vectors.
• laboratory capacity to identify WN virus
  infections in humans and other animal species
• demonstrate/maintain proficiency.
• Conduct data analysis, interpret and disseminate
  results.
• Participate in ArboNET.
• Provide education and public outreach to reduce
  human exposure to WN virus.
• Support prevention activities for WNV and other
  arboviruses.

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WNV-ELC Funding History

• Funding for WNV initiated in 2000
• 188,290,161 disbursed over 10 years
• Ten year, per-state total range
• Minimum 635K (Alaska)
• Maximum 9.8 M (California), 9.7 M (New York)

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ELC WNV FundsTotal Amount Distributed to States
Not Recorded Expenditures by State and Local
Health Departments, Mosquito Control Districts
Cumulative 2000-09 total 188,290,161
distributed to states for WNV
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CDC-Supported Extramural Research Grants

• RFA released in 2000
• 16 priority research areas

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RESEARCH PRIORITIES

• Current and Future Geographic Distribution of WNV
• Bird Migration as a Mechanism of WNV Dispersal
• Vector and Vertebrate Host Relationships and
  Range
• Virus Persistence Mechanisms
• Mosquito Biology, Behavior, Vector Competence,
  Surveillance, and Control
• Development and Evaluation of Prevention
  Strategies
• Laboratory Diagnosis
• Clinical Spectrum of Disease and Long-Term
  Prognosis in Humans
• Risk Factor Studies
• Detailed Clinical Descriptions and Outcome in
  Human Cases
• Viral Pathogenesis
• Genetic Relationships and Molecular Basis of
  Virulence
• Vaccine Development for Animals and Humans
• Antiviral Therapy for West Nile Virus and Other
  Flaviviruses
• Economic Cost of the WNV Epidemic/Epizootic
• WNV Impact on Wildlife
• Investigate Alternate Modes of WNV Transmission
  to Humans

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CDC-Supported Extramural Research Grants

• RFA released in 2000
• 16 priority research areas
• Grants funded in 2001
• 13 grants supported 3 years
• 3 year total 6.5M
• Funding levels (3 year total)
• Min 237 K
• Max 720 K

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CDC-Supported Extramural Research Grants
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NIH Support for WNV-Related Projects 2000-2008
337 Million in past 9 years
228 Projects 2000-08
Estimates of Funding for Various Research,
Condition, and Disease Categories West Nile
Virus, all projects, extramural and
intramural http//report.nih.gov/rcdc/categories/
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West Nile Virus Publications
PubMed Search 1/2/2009, West Nile Virus
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Number of Publications Per Year
10 Year Total WNV 2323 Lyme 2100
Den 3671
PubMed search on term shown, as of 1/2/2009
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WNV Covers on EID
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CDC-Fellowship Training Program in Vector-Borne
Infectious Diseases

• Goal
• Increase the number of specialists with
  demonstrated skills in the public health aspects
  of vector-borne infectious diseases
• Mechanism
• Competitive Grant Cooperative Agreement
• University-Based Training Program

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CDC-Fellowship Training Program in Vector-Borne
Infectious Diseases

• Recipient Activities
• Develop a track of graduate-level study
• Combine entomology, arbovirology, microbiology,
  bacteriology, field, basic laboratory, and
  epidemiologic research in prevention and control
  of vector-borne infectious diseases of public
  health importance.
• Upon completion, fellows will receive a graduate
  degree in the field of study.
• Funding
• 5 M over 5 years

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Training Program Recipients

• Colorado State University
• Barry Beaty
• Tulane Health Sciences Center
• Dawn Wesson
• Yale University
• Durland Fish
• University of Texas Medical Branch
• Steve Higgs

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Training Program Outcomes

• Students
• 28 PhD
• 13 MS
• 15 continuing in program
• 119 Publications

this was the most important grant I had in my
entire career. D. Fish
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The reason for collecting, analyzing and
disseminating information on a disease is to
control that disease. Collection and analysis
should not be allowed to consume resources if
action does not follow.

• Foege W.H. et al. Int. J. of Epidemiology 1976
  529-37.

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Be Prepared.

• Boy Scout Motto
• Lord Robert Baden-Powell

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• Plenary Sessions
• Thursday
• 1 Opening
• 2 Epidemiology
• 3 Clinical Outcomes of WNV Infection
• 4 Ecology
• Friday
• 5 Virology
• 6 Prevention and Control
• 7 Global Arbovirus Threats - Closing

• Poster Sessions
• Thursday
• Poster Session 1 1130 130 with authors of
  odd number posters, Lunch
• Friday
• Poster Session 2 1230 230 with authors of
  even number posters, Lunch
• All poster presenters
• Please put posters on assigned boards before the
  first poster session.

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• Breakout / Discussion Sessions
• Friday - 430 600
• Diagnostic Algorithms
• o West Nile virus diagnostic testing including
  technology improvements, commercial testing, and
  testing algorithms.
• ArboNET/Surveillance
• o The purpose of this session will be to discuss
  preliminary findings from an ongoing evaluation
  of ArboNET, obtain input to develop for a 5-year
  plan for arboviral disease surveillance in the
  U.S., review and potentially revise the national
  arboviral disease case definitions and case
  definitions for blood donors and other non-human
  data.

• Breakout / Discussion Sessions
• Friday - 430 600
• Treatment Trials
• o Review available data from previous treatment
  trials, information on current, ongoing treatment
  trials, how to enroll patients into ongoing
  treatment studies, discussion of experiences
  with, and questions regarding, management of
  patients with WNV illness.
• Ecological Surveillance
• o Exchange comments on the utility of indicators
  from ecological surveillance and discuss how to
  adjust components such as avian mortality
  surveillance to achieve surveillance objectives.