Last data update: May 06, 2024. (Total: 46732 publications since 2009)
Records 1-30 (of 48 Records) |
Query Trace: Waterman SH[original query] |
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Perceptions of Dengue risk and acceptability of a dengue vaccine in residents of Puerto Rico
Rosado-Santiago C , Pérez-Guerra CL , Vélez-Agosto NM , Colón-Burgos C , Marrero-Santos KM , Partridge SK , Lockwood AE , Young C , Waterman SH , Paz-Bailey G , Cardona-Gerena I , Rivera A , Adams LE , Wong JM . Hum Vaccin Immunother 2024 20 (1) 2323264 Dengvaxia is the first dengue vaccine recommended in the United States (U.S.). It is recommended for children aged 9-16 y with laboratory-confirmed previous dengue infection and living in areas where dengue is endemic. We conducted focus groups with parents and in-depth interviews with key informants (i.e. practicing pediatricians, physicians from immunization clinics, university researchers, and school officials) in Puerto Rico (P.R.) to examine acceptability, barriers, and motivators to vaccinate with Dengvaxia. We also carried out informal meetings and semi-structured interviews to evaluate key messages and educational materials with pediatricians and parents. Barriers to vaccination included lack of information, distrust toward new vaccines, vaccine side effects and risks, and high cost of/lack of insurance coverage for laboratory tests and vaccines. Motivators included clear information about the vaccine, a desire to prevent future dengue infections, the experience of a previous dengue infection or awareness of dengue fatality, vaccine and laboratory tests covered by health insurance, availability of rapid test results and vaccine appointments. School officials and parents agreed parents would pay a deductible of $5-20 for Dengvaxia. For vaccine information dissemination, parents preferred an educational campaign through traditional media and social media, and one-on-one counseling of parents by healthcare providers. Education about this vaccine to healthcare providers will help them answer parents' questions. Dengvaxia acceptability in P.R. will increase by addressing motivators and barriers to vaccination and by disseminating vaccine information in plain language through spokespersons from health institutions in P.R. |
Cost-effectiveness of Dengue Vaccination in Puerto Rico (preprint)
España G , Leidner AJ , Waterman SH , Perkins TA . medRxiv 2020 2020.10.07.20208512 An effective and widely used vaccine could reduce the burden of dengue virus (DENV) around the world. DENV is endemic in Puerto Rico, where the dengue vaccine CYD-TDV is currently under consideration as a control measure. CYD-TDV has demonstrated efficacy in clinical trials in vaccinees who had prior dengue infection. However, in vaccinees who had no prior dengue infection, the vaccine had a modestly elevated risk of hospitalization and severe disease. The WHO therefore recommended a strategy of pre-vaccination screening and vaccination of seropositive persons. To estimate the cost-effectiveness and benefits of this intervention (i.e., screening and vaccination of seropositive persons) in Puerto Rico, we simulated 10 years of the intervention in 9-year-olds using an agent-based model. Across the entire population, we found that 5.5% (4.6%-6.3%) of dengue hospitalizations could be averted. However, we also found that 1.6 (1.3 - 2.1) additional hospitalizations could occur for every 1,000 DENV-naïve children who were vaccinated following a false-positive test results for prior exposure. The ratio of the averted hospitalizations among all vaccinees to additional hospitalizations among DENV-naïve vaccinees was estimated to be 19 (13-24). At a base case cost of vaccination of 382 USD, we found an incremental cost-effectiveness ratio of 122,000 USD per QALY gained. Our estimates can provide information for considerations to introduce the CYD-TDV vaccine in Puerto Rico.Competing Interest StatementThe authors have declared no competing interest.Funding StatementThis publication was made possible with partial support from Grant Numbers TL1 TR002531 and UL1 TR002529 (A. Shekhar, PI) from the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:This study does not require ethical guidelines as it's a simulation experimentAll necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesThe data is publicly available |
Identification of risk factors and mosquito vectors associated with dengue virus infection in American Samoa, 2017
Sharp TM , Tufa AJ , Cotter CJ , Lozier MJ , Santiago GA , Johnson SS , Mataia'a M , Waterman SH , Muñoz-Jordán JL , Paz-Bailey G , Hemme RR , Schmaedick MA , Anesi S . PLOS Glob Public Health 2023 3 (7) e0001604 INTRODUCTION: The first outbreak of dengue in American Samoa was reported in 1911. Sporadic outbreaks have been reported since, as were outbreaks of other pathogens transmitted by Aedes species mosquitoes including Ross River, chikungunya, and Zika viruses. During an outbreak of dengue virus-type 2 (DENV-2) in 2016-2018, we conducted household-based cluster investigations to identify population-specific risk factors associated with infection and performed entomologic surveillance to determine the relative abundance of Ae. aegypti and Ae. polynesiensis. METHODS AND FINDINGS: We contacted dengue patients who had tested positive for DENV infection and offered them as well as their household members participation in household-based cluster investigations. For those that accepted participation, we also offered participation to residents of households within a 50-meter radius of each case-patient's home. Questionnaires were administered and serum specimens collected for testing by RT-PCR and anti-DENV IgM ELISA. Adult female mosquitoes were aspirated from inside and outside participating households and tested by RT-PCR. We analyzed characteristics associated with DENV infection in bivariate analyses. A total of 226 participants was enrolled from 91 households in 20 clusters. Median age of participants was 34 years (range: <1-94), and 56.2% were female. In total, 7 (3.2%) participants had evidence of DENV infection by IgM ELISA (n = 5) or RT-PCR (n = 2). Factors significantly associated with DENV infection were reporting a febrile illness in the past three months (prevalence ratio: 7.5 [95% confidence interval: 1.9-29.8]) and having a household septic tank (Fisher's Exact Test, p = 0.004). Of 93 Ae. aegypti and 90 Ae. polynesiensis females collected, 90% of Ae. aegypti were collected inside homes whereas 83% of Ae. polynesiensis were collected outside homes. DENV nucleic acid was not detected in any mosquito pools. Sequencing of the DENV-2 from patient specimens identified the Cosmopolitan genotype of DENV-2 and was most closely related to virus detected in the Solomon Islands during 2016. CONCLUSIONS: This investigation demonstrated that dengue is a continuing risk in American Samoa. Increased frequency of infection among residents with a septic tank suggests a need to investigate whether septic tanks serve as larval habitats for mosquito vectors of DENV in American Samoa. Future efforts should also evaluate the role of Ae. polynesiensis in DENV transmission in the wild. |
Risk factors for infection with chikungunya and Zika viruses in southern Puerto Rico: A community-based cross-sectional seroprevalence survey
Adams LE , Sánchez-González L , Rodriguez DM , Ryff K , Major C , Lorenzi O , Delorey M , Medina FA , Muñoz-Jordán JL , Brown G , Ortiz M , Waterman SH , Rivera-Amill V , Paz-Bailey G . PLoS Negl Trop Dis 2022 16 (6) e0010416 Chikungunya virus (CHIKV) caused a large outbreak in Puerto Rico in 2014, followed by a Zika virus (ZIKV) outbreak in 2016. Communities Organized for the Prevention of Arboviruses (COPA) is a cohort study in southern Puerto Rico, initiated in 2018 to measure arboviral disease risk and provide a platform to evaluate interventions. To identify risk factors for infection, we assessed prevalence of previous CHIKV infection and recent ZIKV and DENV infection in a cross-sectional study among COPA participants. Participants aged 1-50 years (y) were recruited from randomly selected households in study clusters. Each participant completed an interview and provided a blood specimen, which was tested by anti-CHIKV IgG ELISA assay and anti-ZIKV and anti-DENV IgM MAC-ELISA assays. We assessed individual, household, and community factors associated with a positive result for CHIKV or ZIKV after adjusting for confounders. During 2018-2019, 4,090 participants were enrolled; 61% were female and median age was 28y (interquartile range [IQR]: 16-41). Among 4,035 participants tested for CHIKV, 1,268 (31.4%) had evidence of previous infection. CHIKV infection prevalence was lower among children 1-10 years old compared to people 11 and older (adjusted odds ratio [aOR] 2.30; 95% CI 1.71-3.08). Lower CHIKV infection prevalence was associated with home screens (aOR 0.51; 95% CI 0.42-0.61) and air conditioning (aOR 0.64; 95% CI 0.54-0.77). CHIKV infection prevalence also varied by study cluster of residence and insurance type. Few participants (16; 0.4%) had evidence of recent DENV infection by IgM. Among 4,035 participants tested for ZIKV, 651 (16%) had evidence of recent infection. Infection prevalence increased with older age, from 7% among 1-10y olds up to 19% among 41-50y olds (aOR 3.23; 95% CI 2.16-4.84). Males had an increased risk of Zika infection prevalence compared with females (aOR 1.31; 95% CI 1.09-1.57). ZIKV infection prevalence also decreased with the presence of home screens (aOR 0.66; 95% CI 0.54-0.82) and air conditioning (aOR 0.69; 95% CI 0.57-0.84). Similar infection patterns were observed for recent ZIKV infection prevalence and previous CHIKV infection prevalence by age, and the presence of screens and air conditioners in the home decreased infection risk from both viruses by as much as 50%. |
Predominance of severe plasma leakage in pediatric patients with severe dengue in Puerto Rico
Paz-Bailey G , Sánchez-González L , Torres-Velasquez B , Jones E , Perez-Padilla J , Sharp TM , Lorenzi O , Delorey M , Munoz-Jordan J , Tomashek KM , Waterman SH , Alvarado LI , Rivera-Amil V . J Infect Dis 2022 226 (11) 1949-1958 BACKGROUND: We evaluated clinical and laboratory findings among patients with non-severe or severe dengue in Puerto Rico to examine whether clinical manifestations vary by age. METHODS: During 2012-2014, we enrolled patients who arrived at the emergency department with fever or history of fever within 7 days of presentation. Serum samples were tested for dengue virus (DENV) by RT-PCR and IgM ELISA. Severe dengue was defined as severe plasma leakage or shock, severe bleeding, or organ involvement at presentation, during hospitalization, or follow-up. RESULTS: Of 1089 dengue patients identified, 281 (26%) were severe. Compared to those with non-severe dengue, patients with severe dengue were more often aged 10-19 years (55% vs. 40%, p < 0.001) and hospitalized (87% vs. 30%, p < 0.001). Severe plasma leakage or shock was more common among children aged 0-9 (59%) or 10-19 years (86%) than adults (49%) (p < 0.01). Severe bleeding was less common among 10-19 year-olds (24%) compared to 0-9 year-olds (45%) and adults (52%; p < 0.01). CONCLUSIONS: Severe plasma leakage was the most common presentation among children, highlighting important differences with adults. Vaccination against dengue could help prevent severe dengue among children in Puerto Rico. |
Dengue Vaccine: Recommendations of the Advisory Committee on Immunization Practices, United States, 2021
Paz-Bailey G , Adams L , Wong JM , Poehling KA , Chen WH , McNally V , Atmar RL , Waterman SH . MMWR Recomm Rep 2021 70 (6) 1-16 Dengue is a vectorborne infectious disease caused by dengue viruses (DENVs), which are predominantly transmitted by Aedes aegypti and Aedes albopictus mosquitos. Dengue is caused by four closely related viruses (DENV-1-4), and a person can be infected with each serotype for a total of four infections during their lifetime. Areas where dengue is endemic in the United States and its territories and freely associated states include Puerto Rico, American Samoa, the U.S. Virgin Islands, the Federated States of Micronesia, the Republic of Marshall Islands, and the Republic of Palau. This report summarizes the recommendations of the Advisory Committee on Immunization Practices (ACIP) for use of the Dengvaxia vaccine in the United States. The vaccine is a live-attenuated, chimeric tetravalent dengue vaccine built on a yellow fever 17D backbone. Dengvaxia is safe and effective in reducing dengue-related hospitalizations and severe dengue among persons who have had dengue infection in the past. Previous natural infection is important because Dengvaxia is associated with an increased risk for severe dengue in those who experience their first natural infection (i.e., primary infection) after vaccination. Dengvaxia was licensed by the Food and Drug Administration for use among children and adolescents aged 9-16 years (referred to in this report as children). ACIP recommends vaccination with Dengvaxia for children aged 9-16 having evidence of a previous dengue infection and living in areas where dengue is endemic. Evidence of previous dengue infection, such as detection of anti-DENV immunoglobulin G with a highly specific serodiagnostic test, will be required for eligible children before vaccination. |
Tracing the Origin, Spread, and Molecular Evolution of Zika Virus in Puerto Rico, 2016-2017.
Santiago GA , Kalinich CC , Cruz-López F , González GL , Flores B , Hentoff A , Charriez KN , Fauver JR , Adams LE , Sharp TM , Black A , Bedford T , Ellis E , Ellis B , Waterman SH , Paz-Bailey G , Grubaugh ND , Muñoz-Jordán JL . Emerg Infect Dis 2021 27 (11) 2971-2973 We reconstructed the 2016-2017 Zika virus epidemic in Puerto Rico by using complete genomes to uncover the epidemic's origin, spread, and evolutionary dynamics. Our study revealed that the epidemic was propelled by multiple introductions that spread across the island, intricate evolutionary patterns, and ≈10 months of cryptic transmission. |
Cost-effectiveness of dengue vaccination in Puerto Rico
España G , Leidner AJ , Waterman SH , Perkins TA . PLoS Negl Trop Dis 2021 15 (7) e0009606 An effective and widely used vaccine could reduce the burden of dengue virus (DENV) around the world. DENV is endemic in Puerto Rico, where the dengue vaccine CYD-TDV is currently under consideration as a control measure. CYD-TDV has demonstrated efficacy in clinical trials in vaccinees who had prior dengue virus infection. However, in vaccinees who had no prior dengue virus infection, the vaccine had a modestly elevated risk of hospitalization and severe disease. The WHO therefore recommended a strategy of pre-vaccination screening and vaccination of seropositive persons. To estimate the cost-effectiveness and benefits of this intervention (i.e., screening and vaccination of seropositive persons) in Puerto Rico, we simulated 10 years of the intervention in 9-year-olds using an agent-based model. Across the entire population, we found that 5.5% (4.6%-6.3%) of dengue hospitalizations could be averted. However, we also found that 0.057 (0.045-0.073) additional hospitalizations could occur for every 1,000 people in Puerto Rico due to DENV-naïve children who were vaccinated following a false-positive test results for prior exposure. The ratio of the averted hospitalizations among all vaccinees to additional hospitalizations among DENV-naïve vaccinees was estimated to be 19 (13-24). At a base case cost of vaccination of 382 USD, we found an incremental cost-effectiveness ratio of 122,000 USD per QALY gained. Our estimates can provide information for considerations to introduce the CYD-TDV vaccine in Puerto Rico. |
Knowledge gaps in the epidemiology of severe dengue impede vaccine evaluation
Sharp TM , Anderson KB , Katzelnick LC , Clapham H , Johansson MA , Morrison AC , Harris E , Paz-Bailey G , Waterman SH . Lancet Infect Dis 2021 22 (2) e42-e51 The most severe consequences of dengue virus infection include shock, haemorrhage, and major organ failure; however, the frequency of these manifestations varies, and the relative contribution of pre-existing anti-dengue virus antibodies, virus characteristics, and host factors (including age and comorbidities) are not well understood. Reliable characterisation of the epidemiology of severe dengue first depends on the use of consistent definitions of disease severity. As vaccine trials have shown, severe dengue is a crucial interventional endpoint, yet the infrequency of its occurrence necessitates the inclusion of thousands of study participants to appropriately compare its frequency among participants who have and have not been vaccinated. Hospital admission is frequently used as a proxy for severe dengue; however, lack of specificity and variability in clinical practices limit the reliability of this approach. Although previous infection with a dengue virus is the best characterised risk factor for developing severe dengue, the influence of the timing between dengue virus infections and the sequence of dengue virus infections on disease severity is only beginning to be elucidated. To improve our understanding of the diverse factors that shape the clinical spectrum of disease resulting from dengue virus infection, prospective, community-based and clinic-based immunological, virological, genetic, and clinical studies across a range of ages and geographical regions are needed. |
Diagnostic Laboratory Testing and Clinical Preparedness for Dengue Outbreaks during the COVID-19 Pandemic.
Waterman SH , Paz-Bailey G , San Martin JL , Gutierrez G , Castellanos LG , Mendez-Rico JA . Am J Trop Med Hyg 2020 103 (3) 1339-1340 Wilder-Smith and coauthors made key observations regarding the importance of maintaining mosquito control and clinical preparedness for dengue during the COVID-19 pandemic crisis, especially given the resurgence of dengue in Latin America in 2019 and 2020.1–3 Clearly, simultaneous outbreaks of COVID-19 and dengue pose high potential for overwhelming healthcare systems; and because the two diseases can have similar nonspecific clinical presentation in early stages, alerting clinicians and putting in place carefully drawn clinical algorithms for triage are critical to reducing mortality. We would like however to qualify and elaborate on Wilder-Smith et al.’s comment regarding virologic and diagnostic testing in this context. |
Epidemiologic and spatiotemporal trends of Zika Virus disease during the 2016 epidemic in Puerto Rico
Sharp TM , Quandelacy TM , Adams LE , Aponte JT , Lozier MJ , Ryff K , Flores M , Rivera A , Santiago GA , Muñoz-Jordán JL , Alvarado LI , Rivera-Amill V , Garcia-Negrón M , Waterman SH , Paz-Bailey G , Johansson MA , Rivera-Garcia B . PLoS Negl Trop Dis 2020 14 (9) e0008532 BACKGROUND: After Zika virus (ZIKV) emerged in the Americas, laboratory-based surveillance for arboviral diseases in Puerto Rico was adapted to include ZIKV disease. METHODS AND FINDINGS: Suspected cases of arboviral disease reported to Puerto Rico Department of Health were tested for evidence of infection with Zika, dengue, and chikungunya viruses by RT-PCR and IgM ELISA. To describe spatiotemporal trends among confirmed ZIKV disease cases, we analyzed the relationship between municipality-level socio-demographic, climatic, and spatial factors, and both time to detection of the first ZIKV disease case and the midpoint of the outbreak. During November 2015-December 2016, a total of 71,618 suspected arboviral disease cases were reported, of which 39,717 (55.5%; 1.1 cases per 100 residents) tested positive for ZIKV infection. The epidemic peaked in August 2016, when 71.5% of arboviral disease cases reported weekly tested positive for ZIKV infection. Incidence of ZIKV disease was highest among 20-29-year-olds (1.6 cases per 100 residents), and most (62.3%) cases were female. The most frequently reported symptoms were rash (83.0%), headache (64.6%), and myalgia (63.3%). Few patients were hospitalized (1.2%), and 13 (<0.1%) died. Early detection of ZIKV disease cases was associated with increased population size (log hazard ratio [HR]: -0.22 [95% confidence interval -0.29, -0.14]), eastern longitude (log HR: -1.04 [-1.17, -0.91]), and proximity to a city (spline estimated degrees of freedom [edf] = 2.0). Earlier midpoints of the outbreak were associated with northern latitude (log HR: -0.30 [-0.32, -0.29]), eastern longitude (spline edf = 6.5), and higher mean monthly temperature (log HR: -0.04 [-0.05, -0.03]). Higher incidence of ZIKV disease was associated with lower mean precipitation, but not socioeconomic factors. CONCLUSIONS: During the ZIKV epidemic in Puerto Rico, 1% of residents were reported to public health authorities and had laboratory evidence of ZIKV disease. Transmission was first detected in urban areas of eastern Puerto Rico, where transmission also peaked earlier. These trends suggest that ZIKV was first introduced to Puerto Rico in the east before disseminating throughout the island. |
Entomological investigation detects dengue virus type 1 in Aedes (Stegomyia) albopictus (Skuse) during the 2015-16 outbreak in Hawaii
Hasty JM , Felix GE , Amador M , Barrera R , Santiago GS , Nakasone L , Park SY , Okoji S , Honda E , Asuncion B , Save M , Munoz-Jordan JL , Martinez-Conde S , Medina FA , Waterman SH , Petersen LR , Johnston DI , Hemme RR . Am J Trop Med Hyg 2020 102 (4) 869-875 A dengue outbreak occurred on Hawaii Island between September 2015 and March 2016. Entomological investigations were undertaken between December 2015 and February 2016 to determine which Aedes mosquito species were responsible for the outbreak. A total of 3,259 mosquitoes were collected using a combination of CDC autocidal gravid ovitraps, Biogents BG-Sentinel traps, and hand-nets; immature mosquitoes were collected during environmental surveys. The composition of species was Aedes albopictus (58%), Aedes aegypti (25%), Wyeomyia mitchelli (7%), Aedes vexans (5%), Culex quinquefasciatus (4%), and Aedes japonicus (1%). Adult mosquitoes were analyzed by real-time reverse transcription polymerase chain reaction (PCR) for the presence of dengue virus (DENV) RNA. Of the 185 pools of female mosquitoes tested, 15 containing Ae. albopictus were positive for the presence of DENV type 1 RNA. No virus was detected in pools of the remaining species. Phylogenetic analysis showed the virus strain belonged to genotype I and was closely related to strains that were circulating in the Pacific between 2008 and 2014. This is the first report of detection of DENV in Ae. albopictus from Hawaii. |
Travel-associated and locally acquired dengue cases - United States, 2010-2017
Rivera A , Adams LE , Sharp TM , Lehman JA , Waterman SH , Paz-Bailey G . MMWR Morb Mortal Wkly Rep 2020 69 (6) 149-154 Dengue is a potentially fatal acute febrile illness caused by any of four mosquito-transmitted dengue viruses (DENV-1 to DENV-4) belonging to the family Flaviviridae and endemic throughout the tropics. Competent mosquito vectors of DENV are present in approximately one half of all U.S. counties. To describe epidemiologic trends in travel-associated and locally acquired dengue cases in the United States, CDC analyzed cases reported from the 50 states and District of Columbia to the national arboviral surveillance system (ArboNET). Cases are confirmed by detection of 1) virus RNA by reverse transcription-polymerase chain reaction (RT-PCR) in any body fluid or tissue, 2) DENV antigen in tissue by a validated assay, 3) DENV nonstructural protein 1 (NS1) antigen, or 4) immunoglobulin M (IgM) anti-DENV antibody if the patient did not report travel to an area with other circulating flaviviruses. When travel to an area with other flaviviruses was reported, IgM-positive cases were defined as probable. During 2010-2017, totals of 5,009 (93%) travel-associated and 378 (7%) locally acquired confirmed or probable dengue cases were reported to ArboNET. Cases were equally distributed between males and females, and median age was 41 years. Eighteen (three per 1,000) fatal cases were reported, all among travelers. Travelers should review country-specific recommendations (https://wwwnc.cdc.gov/travel/notices/watch/dengue-asia) for reducing their risk for DENV infection, including using insect repellent and staying in residences with air conditioning or screens on windows and doors. |
Comparing vector and human surveillance strategies to detect arbovirus transmission: A simulation study for Zika virus detection in Puerto Rico
Madewell ZJ , Hemme RR , Adams L , Barrera R , Waterman SH , Johansson MA . PLoS Negl Trop Dis 2019 13 (12) e0007988 BACKGROUND: Detecting and monitoring the transmission of arboviruses such as Zika virus (ZIKV), dengue virus, and chikungunya virus is critical for prevention and control activities. Previous work has compared the ability of different human-focused surveillance strategies to detect ZIKV transmission in U.S. counties where no known transmission had occurred, but whether virological surveillance in mosquitoes could represent an effective surveillance system is unclear. OBJECTIVES: We leveraged a unique set of data from human and virological surveillance in Ae. aegypti during the 2016 ZIKV epidemic in Caguas, Puerto Rico, to compare alternative strategies for detecting and monitoring ZIKV activity. METHODS: We developed a simulation model for mosquito and human surveillance strategies and simulated different transmission scenarios with varying infection rates and mosquito trap densities. We then calculated the expected weekly number of detected infections, the probability of detecting transmission, and the number of tests needed and compared the simulations with observed data from Caguas. RESULTS: In simulated high transmission scenarios (1 infection per 1,000 people per week), the models demonstrated that both approaches had estimated probabilities of detection of greater than 78%. In simulated low incidence scenarios, vector surveillance had higher sensitivity than human surveillance and sensitivity increased with more traps, more trapping effort, and testing. In contrast, the actual data from Caguas indicated that human virological surveillance was more sensitive than vector virological surveillance during periods of both high and low transmission. CONCLUSION: In scenarios where human surveillance is not possible or when transmission intensity is very low, virological surveillance in Ae. aegypti may be able to detect and monitor ZIKV epidemic activity. However, surveillance for humans seeking care for Zika-like symptoms likely provides an equivalent or more sensitive indicator of transmission intensity in most circumstances. |
Lessons learned from dengue surveillance and research, Puerto Rico, 1899-2013
Sharp TM , Ryff KR , Santiago GA , Margolis HS , Waterman SH . Emerg Infect Dis 2019 25 (8) 1522-1530 Dengue was first reported in Puerto Rico in 1899 and sporadically thereafter. Following outbreaks in 1963 and 1969, the Centers for Disease Control and Prevention has worked closely with the Puerto Rico Department of Health to monitor and reduce the public health burden of dengue. During that time, evolving epidemiologic scenarios have provided opportunities to establish, improve, and expand disease surveillance and interventional research projects. These initiatives have enriched the tools available to the global public health community to understand and combat dengue, including diagnostic tests, methods for disease and vector surveillance, and vector control techniques. Our review serves as a guide to organizations seeking to establish dengue surveillance and research programs by highlighting accomplishments, challenges, and lessons learned during more than a century of dengue surveillance and research conducted in Puerto Rico. |
Autocidal gravid ovitraps protect humans from chikungunya virus infection by reducing Aedes aegypti mosquito populations
Sharp TM , Lorenzi O , Torres-Velasquez B , Acevedo V , Perez-Padilla J , Rivera A , Munoz-Jordan J , Margolis HS , Waterman SH , Biggerstaff BJ , Paz-Bailey G , Barrera R . PLoS Negl Trop Dis 2019 13 (7) e0007538 BACKGROUND: Public health responses to outbreaks of dengue, chikungunya, and Zika virus have been stymied by the inability to control the primary vector, Aedes aegypti mosquitos. Consequently, the need for novel approaches to Aedes vector control is urgent. Placement of three autocidal gravid ovitraps (AGO traps) in ~85% of homes in a community was previously shown to sustainably reduce the density of female Ae. aegypti by >80%. Following the introduction of chikungunya virus (CHIKV) to Puerto Rico, we conducted a seroprevalence survey to estimate the prevalence of CHIKV infection in communities with and without AGO traps and evaluate their effect on reducing CHIKV transmission. METHODS AND FINDINGS: Multivariate models that calculated adjusted prevalence ratios (aPR) showed that among 175 and 152 residents of communities with and without AGO traps, respectively, an estimated 26.1% and 43.8% had been infected with CHIKV (aPR = 0.50, 95% CI: 0.37-0.91). After stratification by time spent in their community, protection from CHIKV infection was strongest among residents who reported spending many or all weekly daytime hours in their community:10.3% seropositive in communities with AGO traps vs. 48.7% in communities without (PR = 0.21, 95% CI: 0.11-0.41). The age-adjusted rate of fever with arthralgia attributable to CHIKV infection was 58% (95% CI: 46-66%). The monthly number of CHIKV-infected mosquitos and symptomatic residents were diminished in communities with AGO traps compared to those without. CONCLUSIONS: These findings indicate that AGO traps are an effective tool that protects humans from infection with a virus transmitted by Ae. aegypti mosquitos. Future studies should evaluate their protective effectiveness in large, urban communities. |
Dengue and Zika virus diagnostic testing for patients with a clinically compatible illness and risk for infection with both viruses
Sharp TM , Fischer M , Munoz-Jordan JL , Paz-Bailey G , Staples JE , Gregory CJ , Waterman SH . MMWR Recomm Rep 2019 68 (1) 1-10 Dengue and Zika viruses are closely related mosquitoborne flaviviruses with similar transmission cycles, distribution throughout the tropics and subtropics, and disease manifestations including fever, rash, myalgia, and arthralgia. For patients with suspected dengue or Zika virus disease, nucleic acid amplification tests (NAATs) are the preferred method of diagnosis. Immunoglobulin M (IgM) antibody testing can identify additional infections and remains an important tool for the diagnosis of these diseases, but interpreting the results is complicated by cross-reactivity, and determining the specific timing of infection can be difficult. These limitations are a particular challenge for pregnant women in determining whether Zika virus infection occurred during or before the pregnancy.This report summarizes existing and new guidance on dengue and Zika virus diagnostic testing for patients with a clinically compatible illness who live in or recently traveled to an area where there is risk for infection with both viruses. CDC recommendations for screening of asymptomatic pregnant women with possible Zika virus exposure are unchanged. For symptomatic nonpregnant persons, dengue and Zika virus NAATs should be performed on serum collected </=7 days after symptom onset. Dengue and Zika virus IgM antibody testing should be performed on NAAT-negative serum specimens or serum collected >7 days after onset of symptoms. For symptomatic pregnant women, serum and urine specimens should be collected as soon as possible within 12 weeks of symptom onset for concurrent dengue and Zika virus NAATs and IgM antibody testing. Positive IgM antibody test results with negative NAAT results should be confirmed by neutralizing antibody tests when clinically or epidemiologically indicated, including for all pregnant women. Data on the epidemiology of viruses known to be circulating at the location of exposure and clinical findings should be considered when deciding which tests to perform and for interpreting results.Patients with clinically suspected dengue should receive appropriate management to monitor and treat shock and hemorrhage. Women with laboratory evidence of possible Zika virus infection during pregnancy and their infants should be evaluated and managed for possible adverse outcomes. Dengue and Zika virus disease are nationally notifiable conditions, and cases should be reported to public health authorities. |
Citywide control of Aedes aegypti (Diptera: Culicidae) during the 2016 Zika epidemic by integrating community awareness, education, source reduction, larvicides, and mass mosquito trapping
Barrera R , Harris A , Hemme RR , Felix G , Nazario N , Munoz-Jordan JL , Rodriguez D , Miranda J , Soto E , Martinez S , Ryff K , Perez C , Acevedo V , Amador M , Waterman SH . J Med Entomol 2019 56 (4) 1033-1046 This investigation was initiated to control Aedes aegypti and Zika virus transmission in Caguas City, Puerto Rico, during the 2016 epidemic using Integrated Vector Management (IVM), which included community awareness and education, source reduction, larviciding, and mass-trapping with autocidal gravid ovitraps (AGO). The epidemic peaked in August to October 2016 and waned after April 2017. There was a preintervention period in October/November 2016 and IVM lasted until August 2017. The area under treatment (23.1 km2) had 61,511 inhabitants and 25,363 buildings. The city was divided into eight even clusters and treated following a cluster randomized stepped-wedge design. We analyzed pools of female Ae. aegypti adults for RNA detection of dengue (DENV), chikungunya (CHIKV), and Zika (ZIKV) viruses using 360 surveillance AGO traps every week. Rainfall, temperature, and relative humidity were monitored in each cluster. Mosquito density significantly changed (generalized linear mixed model; F8, 14,588 = 296; P < 0.001) from 8.0 +/- 0.1 females per trap per week before the intervention to 2.1 +/- 0.04 after the percentage of buildings treated with traps was 60% and to 1.4 +/- 0.04 when coverage was above 80%. Out of a total 12,081 mosquito pools, there were 1 DENV-, 7 CHIKV-, and 49 ZIKV-positive pools from October 2016 to March 2017. Afterward, we found only one positive pool of DENV in July 2017. This investigation demonstrated that it was possible to scale up effective Ae. aegypti control to a medium-size city through IVM that included mass trapping of gravid Ae. aegypti females. |
Emerging and reemerging Aedes-transmitted arbovirus infections in the region of the Americas: Implications for health policy
Espinal MA , Andrus JK , Jauregui B , Waterman SH , Morens DM , Santos JI , Horstick O , Francis LA , Olson D . Am J Public Health 2019 109 (3) e1-e6 The increasing geographical spread and disease incidence of arboviral infections are among the greatest public health concerns in the Americas. The region has observed an increasing trend in dengue incidence in the last decades, evolving from low to hyperendemicity. Yellow fever incidence has also intensified in this period, expanding from sylvatic-restricted activity to urban outbreaks. Chikungunya started spreading pandemically in 2005 at an unprecedented pace, reaching the Americas in 2013. The following year, Zika also emerged in the region with an explosive outbreak, carrying devastating congenital abnormalities and neurologic disorders and becoming one of the greatest global health crises in years. The inadequate arbovirus surveillance in the region and the lack of serologic tests to differentiate among viruses poses substantial challenges. The evidence for vector control interventions remains weak. Clinical management remains the mainstay of arboviral disease control. Currently, only yellow fever and dengue vaccines are licensed in the Americas, with several candidate vaccines in clinical trials. The Global Arbovirus Group of Experts provides in this article an overview of progress, challenges, and recommendations on arboviral prevention and control for countries of the Americas. (Am J Public Health. Published online ahead of print January 24, 2019: e1-e6. doi:10.2105/AJPH.2018.304849). |
Incidence and outcome of severe and nonsevere thrombocytopenia associated with Zika virus infection - Puerto Rico, 2016
Van Dyne EA , Neaterour P , Rivera A , Bello-Pagan M , Adams L , Munoz-Jordan J , Baez P , Garcia M , Waterman SH , Reyes N , Richardson LC , Rivera-Garcia B , Sharp TM . Open Forum Infect Dis 2019 6 (1) ofy325 Background: Zika virus (ZIKV) infection has been associated with severe thrombocytopenia. We describe the incidence, clinical manifestations, and outcomes of patients with ZIKV infection and thrombocytopenia. Methods: We reviewed medical records of patients with ZIKV infection and thrombocytopenia (platelet count <100 x10(9) cells/L) in Puerto Rico during 2016. Severe thrombocytopenia was defined by platelet count <20 x10(9)/L or a platelet count <50 x10(9)/L and treatment for immune thrombocytopenia (ITP). Results: Of 37 878 patients with ZIKV infection, 47 (0.1%) had thrombocytopenia in the absence of an alternative etiology (1.4 cases/100 000 population), including 12 with severe thrombocytopenia. Most patients with thrombocytopenia were adult (77%) and male (53%). Platelet nadir occurred a median (range) of 6 (1-16) and 5 (0-34) days after symptom onset for patients with severe and nonsevere thrombocytopenia, respectively. Among patients with severe thrombocytopenia, all had bleeding, 33% were admitted to the intensive care unit, and 8% died; 50% were treated for ITP. Among 5 patients with severe thrombocytopenia who received intravenous immunoglobulin, the median platelet count increase (range) was 112 (65-202) x10(9)/L. In contrast, among 4 patients who received platelet transfusion, the median increase in platelet count (range) was 8.5 (-6 to 52) x10(9)/L. Conclusions: Patients with severe thrombocytopenia and ZIKV infection experienced prominent acute morbidity. Consistent with recommended management, administration of ITP treatments to such patients may be more efficacious than platelet transfusion in resolving thrombocytopenia. Severe thrombocytopenia should be considered a rare outcome of ZIKV infection. |
Implementation and Evaluation of Guillain-Barre Syndrome Surveillance in Puerto Rico during the 2016 Zika Virus Epidemic
Major CG , Dirlikov E , Medina NA , Lugo-Robles R , Matos D , Munoz-Jordan J , Colon-Sanchez C , Garcia-Negron M , Olivero-Segarra M , Malave-Gonzalez G , Thomas DL , Luciano CA , Waterman SH , Sejvar J , Sharp TM , Rivera-Garcia B . P R Health Sci J 2018 37 S85-s92 OBJECTIVE: Guillain-Barre syndrome (GBS) is an uncommon autoimmune disorder that follows infection or vaccination, and increased incidence has been reported during Zika virus (ZIKV) transmission. During the 2016 ZIKV epidemic, the Puerto Rico Department of Health (PRDH) implemented the Enhanced GBS Surveillance System (EGBSSS). Here, we describe EGBSSS implementation and evaluate completeness, validity, and timeliness. METHODS: GBS cases were identified using passive surveillance and discharge diagnostic code for GBS. Completeness was evaluated by capture-recapture methods. Sensitivity and positive predictive value (PPV) for confirmed GBS cases were calculated for both case identification methods. Median time to completion of key time steps were compared by quarter (Q1-4) and hospital size. RESULTS: A total of 122 confirmed GBS cases with onset of neurologic illness in 2016 were identified. Capture-recapture methodology estimated that four confirmed GBS cases were missed by both identification methods. Identification of cases by diagnostic code had a higher sensitivity than passive surveillance (89% vs. 80%), but a lower PPV (60% vs. 72%). There was a significant decrease from Q1 to Q3 in median time from hospital admission to case reporting (11 days vs. 2 days, p = 0.032) and from Q2 to Q3 in median time from specimen receipt to arbovirus laboratory test reporting (35 days vs. 26 days, p = 0.004). CONCLUSION: EGBSSS provided complete, valid, and increasingly timely surveillance data, which guided public health action and supported healthcare providers during the ZIKV epidemic. This evaluation provides programmatic lessons for GBS surveillance and emergency response surveillance. |
Clinical features of Guillain-Barre syndrome with vs without Zika virus infection, Puerto Rico, 2016
Dirlikov E , Major CG , Medina NA , Lugo-Robles R , Matos D , Munoz-Jordan JL , Colon-Sanchez C , Garcia M , Olivero-Segarra M , Malave G , Rodriguez-Vega GM , Thomas DL , Waterman SH , Sejvar JJ , Luciano CA , Sharp TM , Rivera-Garcia B . JAMA Neurol 2018 75 (9) 1089-1097 Importance: The pathophysiologic mechanisms of Guillain-Barre syndrome (GBS) associated with Zika virus (ZIKV) infection may be indicated by differences in clinical features. Objective: To identify specific clinical features of GBS associated with ZIKV infection. Design, Setting, and Participants: During the ZIKV epidemic in Puerto Rico, prospective and retrospective strategies were used to identify patients with GBS who had neurologic illness onset in 2016 and were hospitalized at all 57 nonspecialized hospitals and 2 rehabilitation centers in Puerto Rico. Guillain-Barre syndrome diagnosis was confirmed via medical record review using the Brighton Collaboration criteria. Specimens (serum, urine, cerebrospinal fluid, and saliva) from patients with GBS were tested for evidence of ZIKV infection by real-time reverse transcriptase-polymerase chain reaction; serum and cerebrospinal fluid were also tested by IgM enzyme-linked immunosorbent assay. In this analysis of public health surveillance data, a total of 123 confirmed GBS cases were identified, of which 107 had specimens submitted for testing; there were 71 patients with and 36 patients without evidence of ZIKV infection. Follow-up telephone interviews with patients were conducted 6 months after neurologic illness onset; 60 patients with and 27 patients without evidence of ZIKV infection participated. Main Outcomes and Measures: Acute and long-term clinical characteristics of GBS associated with ZIKV infection. Results: Of 123 patients with confirmed GBS, the median age was 54 years (age range, 4-88 years), and 68 patients (55.3%) were male. The following clinical features were more frequent among patients with GBS and evidence of ZIKV infection compared with patients with GBS without evidence of ZIKV infection: facial weakness (44 [62.0%] vs 10 [27.8%]; P < .001), dysphagia (38 [53.5%] vs 9 [25.0%]; P = .005), shortness of breath (33 [46.5%] vs 9 [25.0%]; P = .03), facial paresthesia (13 [18.3%] vs 1 [2.8%]; P = .03), elevated levels of protein in cerebrospinal fluid (49 [94.2%] vs 23 [71.9%]; P = .008), admission to the intensive care unit (47 [66.2%] vs 16 [44.4%]; P = .03), and required mechanical ventilation (22 [31.0%] vs 4 [11.1%]; P = .02). Six months after neurologic illness onset, patients with GBS and evidence of ZIKV infection more frequently reported having excessive or inadequate tearing (30 [53.6%] vs 6 [26.1%]; P = .03), difficulty drinking from a cup (10 [17.9%] vs 0; P = .03), and self-reported substantial pain (15 [27.3%] vs 1 [4.3%]; P = .03). Conclusions and Relevance: In this study, GBS associated with ZIKV infection was found to have higher morbidity during the acute phase and more frequent cranial neuropathy during acute neuropathy and 6 months afterward. Results indicate GBS pathophysiologic mechanisms that may be more common after ZIKV infection. |
Vital Signs: Trends in reported vectorborne disease cases - United States and Territories, 2004-2016
Rosenberg R , Lindsey NP , Fischer M , Gregory CJ , Hinckley AF , Mead PS , Paz-Bailey G , Waterman SH , Drexler NA , Kersh GJ , Hooks H , Partridge SK , Visser SN , Beard CB , Petersen LR . MMWR Morb Mortal Wkly Rep 2018 67 (17) 496-501 INTRODUCTION: Vectorborne diseases are major causes of death and illness worldwide. In the United States, the most common vectorborne pathogens are transmitted by ticks or mosquitoes, including those causing Lyme disease; Rocky Mountain spotted fever; and West Nile, dengue, and Zika virus diseases. This report examines trends in occurrence of nationally reportable vectorborne diseases during 2004-2016. METHODS: Data reported to the National Notifiable Diseases Surveillance System for 16 notifiable vectorborne diseases during 2004-2016 were analyzed; findings were tabulated by disease, vector type, location, and year. RESULTS: A total 642,602 cases were reported. The number of annual reports of tickborne bacterial and protozoan diseases more than doubled during this period, from >22,000 in 2004 to >48,000 in 2016. Lyme disease accounted for 82% of all tickborne disease reports during 2004-2016. The occurrence of mosquitoborne diseases was marked by virus epidemics. Transmission in Puerto Rico, the U.S. Virgin Islands, and American Samoa accounted for most reports of dengue, chikungunya, and Zika virus diseases; West Nile virus was endemic, and periodically epidemic, in the continental United States. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Vectorborne diseases are a large and growing public health problem in the United States, characterized by geographic specificity and frequent pathogen emergence and introduction. Differences in distribution and transmission dynamics of tickborne and mosquitoborne diseases are often rooted in biologic differences of the vectors. To effectively reduce transmission and respond to outbreaks will require major national improvement of surveillance, diagnostics, reporting, and vector control, as well as new tools, including vaccines. |
Collection of data on race, ethnicity, language, and nativity by US Public Health Surveillance and Monitoring Systems: Gaps and opportunities
Rodriguez-Lainz A , McDonald M , Fonseca-Ford M , Penman-Aguilar A , Waterman SH , Truman BI , Cetron MS , Richards CL . Public Health Rep 2017 133 (1) 33354917745503 OBJECTIVE: Despite increasing diversity in the US population, substantial gaps in collecting data on race, ethnicity, primary language, and nativity indicators persist in public health surveillance and monitoring systems. In addition, few systems provide questionnaires in foreign languages for inclusion of non-English speakers. We assessed (1) the extent of data collected on race, ethnicity, primary language, and nativity indicators (ie, place of birth, immigration status, and years in the United States) and (2) the use of data-collection instruments in non-English languages among Centers for Disease Control and Prevention (CDC)-supported public health surveillance and monitoring systems in the United States. METHODS: We identified CDC-supported surveillance and health monitoring systems in place from 2010 through 2013 by searching CDC websites and other federal websites. For each system, we assessed its website, documentation, and publications for evidence of the variables of interest and use of data-collection instruments in non-English languages. We requested missing information from CDC program officials, as needed. RESULTS: Of 125 data systems, 100 (80%) collected data on race and ethnicity, 2 more collected data on ethnicity but not race, 26 (21%) collected data on racial/ethnic subcategories, 40 (32%) collected data on place of birth, 21 (17%) collected data on years in the United States, 14 (11%) collected data on immigration status, 13 (10%) collected data on primary language, and 29 (23%) used non-English data-collection instruments. Population-based surveys and disease registries more often collected data on detailed variables than did case-based, administrative, and multiple-source systems. CONCLUSIONS: More complete and accurate data on race, ethnicity, primary language, and nativity can improve the quality, representativeness, and usefulness of public health surveillance and monitoring systems to plan and evaluate targeted public health interventions to eliminate health disparities. |
Differences in prevalence of symptomatic Zika virus infection by age and sex - Puerto Rico, 2016
Lozier MJ , Burke RM , Lopez J , Acevedo V , Amador M , Read JS , Jara A , Waterman SH , Barrera R , Munoz-Jordan J , Garcia-Rivera B , Sharp TM . J Infect Dis 2017 217 (11) 1678-1689 Background: During the Zika virus (ZIKV) outbreak in Puerto Rico in 2016, non-pregnant women aged 20-39 years were disproportionately identified with ZIKV disease. We used household-based cluster investigations to determine if this disparity was associated with age- or sex-dependent differences in the rate of ZIKV infection or reporting symptoms. Methods: Participation was offered to residents of households within a 100-meter radius of the residences of a convenience sample of 19 laboratory-confirmed ZIKV disease cases. Participants answered a questionnaire and provided specimens for diagnostic testing by RT-PCR and ELISA. Results: Among 367 study participants, 114 (31.1%) were laboratory-positive for ZIKV infection, of which 30% reported a recent illness (defined as self-reported rash or arthralgia) attributable to ZIKV infection. Age and sex were not associated with ZIKV infection. Female sex (adjusted prevalence ratio [aPR]=2.28; 95% confidence interval [CI]=1.40, 3.67), age <40 years (aPR=2.39; 95% CI=1.55, 3.70), and asthma (aPR=1.63; 95% CI=1.12, 2.37) were independently associated with symptomatic infection. Conclusions: Although neither female sex nor age were associated with increased prevalence of ZIKV infection, both were associated with symptomatic infection. Further investigation to identify a potential mechanism of age- and sex-dependent differences in reporting symptomatic ZIKV infection is warranted. |
Epidemiological surveillance of land borders in North and South America: a case study
Bruniera-Oliveira R , Horta MAP , Varan A , Montiel S , Carmo EH , Waterman SH , Verani JFS . Rev Inst Med Trop Sao Paulo 2017 59 e68 This study aims to analyze the different binational/multinational activities, programs, and structures taking place on the borders of Brazil and the U.S. between 2013 and 2015. A descriptive exploratory study of two border epidemiological surveillance (BES) systems has been performed. Two approaches were used to collect data: i) technical visits to the facilities involved with border surveillance and application of a questionnaire survey; ii) application of an online questionnaire survey. It was identified that, for both surveillance systems, more than 55% of the technicians had realized that the BES and its activities have high priority. Eighty percent of North American and 71% of Brazilian border jurisdictions reported an exchange of information between countries. Less than half of the jurisdictions reported that the necessary tools to carry out information exchange were available. Operational attributes of completeness, feedback, reciprocity, and quality of information were identified as weak or of low quality in both systems. Statements, guidelines, and protocols to develop surveillance activities are available at the U.S.-Mexico border area. The continuous systematic development of surveillance systems at these borders will create more effective actions and responses. |
Serological susceptibility to varicella among U.S. Immigration and Customs Enforcement detainees
Varan AK , Lederman ER , Stous SS , Elson D , Freiman JL , Marin M , Lopez AS , Stauffer WM , Joseph RH , Waterman SH . J Correct Health Care 2017 24 (1) 1078345817727287 U.S. Immigration and Customs Enforcement (ICE) is responsible for detaining unauthorized aliens during immigration proceedings. During 2014 to 2015, adult ICE detainees at a California facility were invited to complete a survey concerning self-reported varicella history and risk factors. Participants underwent serological testing for varicella-zoster virus (VZV) IgG; susceptible individuals were offered varicella vaccination. Among 400 detainees with available serology results, 48 (12%) were susceptible to varicella. Self-reported varicella history was negatively associated with susceptibility (adjusted odds ratio = 0.16; 95% confidence interval [0.07, 0.35]). Among 196 detainees reporting a positive history, 95% had VZV IgG levels suggestive of varicella immunity. Among 44 susceptible detainees offered vaccination, 86% accepted. Given relatively high varicella susceptibility, targeted screening and vaccination among ICE detainees lacking a positive history might reduce varicella transmission risks. |
A decade of arboviral activity-Lessons learned from the trenches
Powers AM , Waterman SH . PLoS Negl Trop Dis 2017 11 (4) e0005421 In the ten years during which PLOS Neglected Tropical Diseases has been publishing, it has become known as a critical journal for describing new and ground-breaking research in arbovirology. In its first year in existence, ten arboviral papers were published in this journal while last year, 157 arboviral papers were published here. In just the past decade, outbreaks of dengue, chikungunya, and most recently Zika have demonstrated how ever-increasing globalization has made mosquito-borne pathogens some of the most significant public health concerns known. During this time, even as these agents have become more prominent, significant advances have been made in understanding how to combat them. | Over ten years ago, the little known chikungunya virus (CHIKV), came to be known globally after an outbreak occurred in the resort island of La Reunion, leading to dozens of reported cases in European travelers and concern for how far it might move [1]. The virus spread to India where over 1 million cases were reported that year alone [2]. Both East Africa and India had previously experienced CHIKV activity, but the virus continued to spread over the next several years to subtropical latitudes and throughout the Americas where over 2.3 million infections have been reported to date. Just as CHIKV affected nearly every country in the Americas, Zika virus (ZIKAV), which was previously unknown to even most flavivirologists, was introduced into the Americas, leading to one of the largest global public health crises in years [3]. ZIKAV not only caused traditional vector-borne transmission febrile illness but was also found to be transmitted sexually and to cause devastating congenital abnormalities. During this same decade, while the high-profile CHIKV and ZIKAV outbreaks were in the news, outbreaks due to dengue viruses continued to occur with little fanfare. Dengue viruses still remain the leading cause of arboviral disease and are estimated to cause approximately 390 million infections per year [4]. |
A new look at an old disease: Recent insights into the global epidemiology of dengue
Sharp TM , Tomashek KM , Read JS , Margolis HS , Waterman SH . Curr Epidemiol Rep 2017 4 (1) 11-21 PURPOSE OF REVIEW: By all measures, the morbidity and mortality due to dengue are continuing to worsen worldwide. Although both early and recent studies have demonstrated regional differences in how dengue affects local populations, these findings were to varying extents related to disparate surveillance approaches. RECENT FINDINGS: Recent studies have broadened the recognized spectrum of disease resulting from DENV infection, particularly in adults, and have also demonstrated new mechanisms of DENV spread both within and between populations. New results regarding the frequency and duration of homo- and heterotypic anti-DENV antibodies have provided important insights relevant to vaccine design and implementation. SUMMARY: These observations and findings as well as difficulties in comparing the epidemiology of dengue within and between regions of the world underscore the need for population-based dengue surveillance worldwide. Enhanced surveillance should be implemented to complement passive surveillance in countries in the tropics to establish baseline data in order to define affected populations and evaluate the impact of dengue vaccines and novel vector control interventions. |
Persistence of Zika Virus in Body Fluids - Final Report
Paz-Bailey G , Rosenberg ES , Doyle K , Munoz-Jordan J , Santiago GA , Klein L , Perez-Padilla J , Medina FA , Waterman SH , Gubern CG , Alvarado LI , Sharp TM . N Engl J Med 2017 Background To estimate the frequency and duration of detectable Zika virus (ZIKV) RNA in human body fluids, we prospectively assessed a cohort of newly infected participants in Puerto Rico. Methods We evaluated samples obtained from 150 participants (including 55 men) in whom ZIKV RNA was detected on reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay in urine or blood in an enhanced arboviral clinical surveillance site. We collected serum, urine, saliva, semen, and vaginal secretions weekly for the first month and then at 2, 4, and 6 months. All specimens were tested by means of RT-PCR, and serum was tested with the use of anti-ZIKV IgM enzyme-linked immunosorbent assay. Among the participants with ZIKV RNA in any specimen at week 4, biweekly collection continued until all specimens tested negative. We used parametric Weibull regression models to estimate the time until the loss of ZIKV RNA detection in each body fluid and reported the findings in medians and 95th percentiles. Results The medians and 95th percentiles for the time until the loss of ZIKV RNA detection were 14 days (95% confidence interval [CI], 11 to 17) and 54 days (95% CI, 43 to 64), respectively, in serum; 8 days (95% CI, 6 to 10) and 39 days (95% CI, 31 to 47) in urine; and 34 days (95% CI, 28 to 41) and 81 days (95% CI, 64 to 98) in semen. Few participants had detectable ZIKV RNA in saliva or vaginal secretions. Conclusions The prolonged time until ZIKV RNA clearance in serum in this study may have implications for the diagnosis and prevention of ZIKV infection. Current sexual-prevention guidelines recommend that men use condoms or abstain from sex for 6 months after ZIKV exposure; in 95% of the men in this study, ZIKV RNA was cleared from semen after about 3 months. (Funded by the Centers for Disease Control and Prevention.). |
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