Viruses, of course, do not live independently outside of their hosts. Rather, they are uniquely bundled bits of data that use the body of their victim to replicate. We group viruses into families based on similar packaging and properties. Comparative virology examines the differences and similarities among viruses, and sometimes these comparisons can suggest answers for unknowns about a specific virus.

Today, growing concern about birth defects linked to Zika virus is a newsworthy medical mystery. Uncertainty about the risk of exposure has led to widespread warnings for pregnant women and those of child-bearing age.

While Zika’s varied manifestations – ranging from a complete lack of clinical disease to (potential) birth defects – are sensationalized in the media, an outbreak with this constellation of clinical signs is not unprecedented in the animal kingdom.

Zika is a member of the Flaviviridae family. This viral family includes a diverse array of pathogens affecting humans and animals, including hepatitis C, dengue, and many other diseases important to public health. Other members of this family might provide clues in cracking Zika’s pathogenesis.

The Flaviviridae family contains four genuses [1]. Flaviviridae flavivirus is the largest genus and is often insect-borne. Many dozens of species in the flavivirus genus have been identified, including some important zoonotic diseases. West Nile Virus, Japanese Encephalitis Virus, and Yellow Fever join Zika virus is in this genus [2]

The next largest genus of Flaviviridae is the Flaviviridae pestivirus. Pestiviruses are not classically spread by insect vectors, but rather via transfer of bodily fluids. The pestiviruses are a smaller group, with four species described [3]. Though these viruses have important differences from what we know about Zika virus, pestiviruses may still aid in conceptually understanding the behavior of Zika virus in pregnant women. As is suspected in Zika virus, one of the hallmarks of pestiviruses is vertical transmission, which means that the unborn fetus is affected if the mother is infected while pregnant [4].

Bovine viral diarrhea virus (BVDV) is an important pestivirus in the Flaviviridae family. BVDV’s complex effects have fueled scientific discovery since the disease was first recognized in the 1940s [5]. Its clinical signs range from transient infection, with no signs of clinical disease, to severe illness and death in affected livestock. Some of the most interesting effects of BVDV are seen in the reproductive and immune systems.

In the event of vertical transmission, BVDV can cause a variety of problems for the calf. The mother’s stage of pregnancy when exposed to BVDV dramatically impacts fetal outcomes, and the infection can cause pregnancy loss and birth defects.
               
How BVDV affects fetal development depends on the timing of maternal infection during pregnancy. The eyes and central nervous system are targets of the virus, and characteristic deformations of the brain and skull are observed. These deformities include hydranencephaly, hydrocephalus, and microencephaly [6].

BVDV is not transmissible to people but can infect a number of ruminants. Other species in the pestivirus family – siblings to bovine viral diarrhea – include border disease of sheep and classical swine fever in pigs. All of these pestiviruses can cause birth deformities.

Another fascinating aspect of pestiviruses is that they can affect host immunity during infection. BVDV is capable of becoming a “persistent infection” that is never fully cleared from the body. Persistent infection can happen in a number of ways. BVDV can manipulate the mechanisms that identify pathogens in the body. The virus is therefore camouflaged as “self” and avoids targeting by the immune system [7]. Calves may be born persistently infected if the virus reaches the unborn baby during early development, before the immune system has the maturity to respond. The lack of immune resistance in the fetus causes the newborn to be persistently infected with the disease. This condition – namely, immune tolerance to the disease – has lifelong implications for the calf. In the case of BVD, a variety of clinical outcomes can occur in persistently infected neonates, and this diversity is partly explained by existence of multiple genotypes and biotypes of the virus.

Persistently infected animals are important in the spread of BVD and have led to endemic status around the world. Testing can be challenging; animals lacking antibodies might still be infected with the virus.    Proven methods of infection from BVDV range from direct contact to sexual transmission, among others. Because animals show a range of clinical disease—from apparent health, immune suppression, co-infections, ulcerated mucous membranes, decreased lactation, gastro-intestinal disease, fevers, abortion, diarrhea, respiratory disease, to birth defects— BVD may go unidentified until widespread.

Like Zika, BVD was initially identified as a disease with nonspecific clinical signs – particularly, diarrhea [8] – but has since been shown to have a complex web of implications. Many brilliant scientists have contributed to the discovery of BVDV’s properties as a pathogen, largely because of its worldwide ubiquity and its economic impact on the livestock industry.

While Zika virus belongs to a different genus of Flaviviridae than BVDV and will undoubtedly attack its host in unique, undiscovered ways, its cousin in the pestivirus family offers an interesting parallel. Regardless of the pathophysiology of Zika virus that is ultimately discovered, Zika’s range of clinical signs will, like BVDV, certainly fuel investigation and publication for decades to come.

Supplementary Material: Zika virus vs. Bovine viral diarrhea virus, at a glance 

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References

[1]  International Committee on Taxonomy of Viruses. Virus Taxonomy: 2014 Release. EC 46. Montreal, Canada Email ratification 2015 (MSL#29). [Online] Copyright 2016. [Cited: Feb 02, 2016.] Retrieved from http://ictvonline.org/virusTaxonomy.asp

[2] International Committee on Taxonomy of Viruses. Virus Taxonomy: 2014 Release. EC 46. Montreal, Canada Email ratification 2015 (MSL#29). [Online] Copyright 2016. [Cited: Feb 02, 2016.] Retrieved from http://ictvonline.org/virusTaxonomy.asp

[3] International Committee on Taxonomy of Viruses. Copyright 2016.
Virus Taxonomy: 2014 Release.  EC 46. Montreal, Canada Email ratification 2015 (MSL#29).
Retrieved from http://ictvonline.org/virusTaxonomy.asp

[4] Besnard M, Lastère S, Teissier A, Cao-Lormeau VM, Musso D. Evidence of perinatal transmission of Zika virus, French Polynesia, December 2013 and February 2014 . Euro Surveill. 2014;19(13):pii=20751. Article DOI: http://dx.doi.org/10.2807/1560-7917.ES2014.19.13.20751 Accessed Feb 6 2016. http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20751

[5] Maclachlan, N. James;Dubovi, Edward J. 2010., Fenner's Veterinary Virology. [online]. Academic Press. Available from:<http://www.myilibrary.com?ID=295474> 4 February 2016  Chapter 30: Flaviviridae. p 475. 
DOI: 10.1016/B978-0-12-375158-4.00030-4

[6] Agerholm JS, Hewicker-Trautwein M, Peperkamp K, Windsor PA. Virus-induced congenital malformations in cattle. Acta Veterinaria Scandinavica. 2015;57(1):54. doi:10.1186/s13028-015-0145-8.

Hewicker-Trautwein M, Liess B, Trautwein G. Brain lesions in calves following transplacental infection with bovine-virus diarrhea virus. J Vet Med B. 1995;42:65–77. doi: 10.1111/j.1439-0450.1995.tb00684.x.

Badman RT, Mitchell G, Jones RT, Westbury HA. Association of bovine viral diarrhea virus infection to hydranencephaly and other central nervous system lesions in perinatal calves. Aust Vet J. 1981;57:306–307. doi: 10.1111/j.1751-0813.1981.tb05831.x

[7] Ernst Peterhans, Matthias Schweizer, BVDV: A pestivirus inducing tolerance of the innate immune response, Biologicals, Volume 41, Issue 1, January 2013, Pages 39-51, ISSN 1045-1056, http://dx.doi.org/10.1016/j.biologicals.2012.07.006.

[8] Maclachlan, N. James;Dubovi, Edward J. 2010., Fenner's Veterinary Virology. [online]. Academic Press. Available from:<http://www.myilibrary.com?ID=295474> 4 February 2016  Chapter 30: Flaviviridae. p 475. DOI: 10.1016/B978-0-12-375158-4.00030-4

Info Sheet: Bovine Viral Diarrhea Virus. United States Department of Agriculture- Veterinary Services- Centers for Epidemiology and Animal Health.  Fort Collins, CO. December 2007.

Maclachlan, N. James;Dubovi, Edward J. 2010., Fenner's Veterinary Virology. [online]. Academic Press. Available from:<http://www.myilibrary.com?ID=295474> 4 February 2016  Chapter 30: Flaviviridae.  

DOI: 10.1016/B978-0-12-375158-4.00030-4

Merck Veterinary Manual [online] Copyright 2009-2015 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, N.J., U.S.A.   “Overview of Congenital and Inherited Anomalies” Last full review/revision October 2015 by Dana G. Allen, DVM, MSc, DACVIM; Andrew Dart, BVSc, PhD, DACVS, DECVS Accessed Feb 4,

M.R. McGowan, P.D. Kirkland, Early reproductive loss due to bovine pestivirus infection, British Veterinary Journal, Volume 151, Issue 3, May–June 1995, Pages 263-270, ISSN 0007-1935, http://dx.doi.org/10.1016/S0007-1935(95)80176-2016. 

Sasha R. Lanyon, Fraser I. Hill, Michael P. Reichel, Joe Brownlie, Bovine viral diarrhoea: Pathogenesis and diagnosis, The Veterinary Journal, Volume 199, Issue 2, February 2014, Pages 201-209, ISSN 1090-0233, http://dx.doi.org/10.1016/j.tvjl.2013.07.024.

Peterhans, Ernst, and Matthias Schweizer. Pestiviruses: How to Outmaneuver Your Hosts. http://dx.doi.org/10.1016/j.vetmic.2009.09.038

Ernst Peterhans, Matthias Schweizer, BVDV: A pestivirus inducing tolerance of the innate immune response, Biologicals, Volume 41, Issue 1, January 2013, Pages 39-51, ISSN 1045-1056, http://dx.doi.org/10.1016/j.biologicals.2012.07.006.

In Venezuela, there have been reports of over 5,000 suspected cases of the Zika virus [1, 2] – a virus with potential links to severe birth defects in thousands of newborns in Brazil, and potentially related to the autoimmune disease, Guillain-Barre syndrome [3, 4].

Independent experts believe that the actual number of Zika cases in Venezuela is significantly underestimated. Using mathematical modeling and official government data, Julio Castro, a professor of tropical epidemiology at the Central University of Venezuela, has estimated that roughly 400,000 people may have been infected with the Zika virus in Venezuela [5, 6]. Scientists from the Independent Network to Defend National Epidemiology (NDNE) have arrived at numbers similar to Castro’s estimations [5]. If these numbers are correct, Venezuela could have a higher per-capita rate of Zika infection than Brazil. Furthermore, the mosquito responsible for carrying the Zika virus -  Aedes aegypti - is present in approximately 20 percent of Venezuelan homes, compared to only five percent of homes in Brazil.[6]. With more mosquitoes available to spread, it is very likely that Zika could be more prevalent in Venezuela than in Brazil [7].

Recently, Venezuelan President Nicolas Maduro was accused of failing to acknowledge the true extent of tropical disease burden in Venezuela, such as dengue, malaria, and Chikungunya [8]. Huniades Urbina-Medina, the president of the Venezuelan Pediatric Society, has even cited that the Venezuelan government has suspended publication of the weekly health reports demonstrating a reluctance to fully address the current number of cases of infectious diseases in the country [6, 9]. Without reliable and transparent information on the number of Zika cases, Urbina-Medina fears that Venezuela could be on the verge of an even more severe wave of birth defects than those witnessed in Brazil, if the link between Zika and microcephaly is true. The first wave of babies born to mothers potentially exposed to Zika is expected to begin in March and April of this year [6].

According to the World Health Organization (WHO), the rapidly emerging Zika virus is estimated to affect as many as four million people throughout the Americas this year, including people in the United States and Mexico [10]. As Venezuela is in the midst of a severe economic crisis, the government has cut water supplies by up to 29% [11]. As a result, residents in slums across the country have been forced to store water in their homes, which has led to an increase in standing water, a favored habitat of mosquitoes that enables breeding. This risks perpetuating Zika’s spread. Coupled with the ongoing economic crisis, lack of infrastructure, political turmoil, and shortages of basic supplies including medical necessities, Urbina-Medina reported that Venezuela is “exposed like no other country in Latin America for this to be a pandemic” [2].

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Sources

1.         France-Presse, A., Venezuela reprts 4,700 suspected Zika cases, in Global Post. 2016.

2.         Ulmer, A., Pregnant women in scarcity-hit Venezuela battle to dodge Zika, in Reuters. 2016.

3.         Ellis, F., Ahead of Print: Epidemiologists Are Tracking Possible Links Between Zika Virus and Guillain–Barré Syndrome. Neurology Today, 2016.

4.         Jr, D.G.M., Hawaii Baby With Brain Damage Is First U.S. Case Tied to Zika Virus, in New York Times. 2016.

5.         Romero, S., Reports of Zika-Linked Birth Defect Rise in Brazil, in New York Times. 2016.

6.         Tegel, S., There's a chance Venezuela's Zika outbreak is worse than Brazil's, in Global Post. 2016.

7.         Hayes, E.B., et al., Epidemiology and transmission dynamics of West Nile virus disease. Emerging infectious diseases, 2005. 11(8).

8.         Venezuela in grip of severe tropical disease outbreak, in Yahoo News. 2014.

9.         Yanes, M., What happened to the National Epidemiological Bulletin?, in El Nacional. 2015.

10.       Taversnise, S., Zika Virus ‘Spreading Explosively’ in Americas, W.H.O. Says, in New York Times. 2016: New York Times.

11.       Lagorio, J.J., Venezuela cuts water supply in Maracaibo as crisis bites, in BN americas. 2014.

Scientists are concerned that the recent mysterious deaths of howler monkeys in Nicaragua could be a result of the Zika Virus. Recently, nearly 40 howler monkeys have been found dead in the tropical region, with no apparent signs of trauma [1].

Paso Pacifico, an environmental non-profit organization that works in the Pacific jungles of Central America, is leading the efforts to determine what the cause of death is for these monkeys.

The howler monkey is a New World Monkey found in tropical Central and South America, and is well known for its harsh and stinging cries. [2].

Kim Williams-Guillen, a conservation researcher, who has been researching in Nicaragua’s jungles since 1999, told the Global Post, “Wild animals die off all the time, but it is really unusual to see this many deaths in such a short time with no apparent reason…I have never seen anything like it” [3].

The Zika virus, a flavivirus carried by the Aedes aegypti mosquito, has been rapidly spreading throughout South and Central America. Its surge in human cases within recent months have led experts to question whether it may play a role in the mysterious die-off of the tropical monkeys. While Zika virus is a suspected cause of the recent surge in deaths of howler monkeys, a confirmed direct link remains quite unclear Both Zika virus and Chikungunya are vector-borne diseases carried by the same mosquito that carries Dengue and are relatively new to the Western Hemisphere. There is relatively little research published on the effects of Zika and Chikungunya in humans, let alone in the wild monkey population, who are infected via the mosquito just as humans are. Nicaragua has reported 29 cases of Zika in humans so far, and approximately 100,000 cases of Chikungunya since 2014. However, it has not yet been researched how either of these diseases affect primates [1].

What we do know is that howler monkeys are immune to dengue, but are highly susceptible to yellow fever [1]. Yellow fever causes mild symptoms in most species of Old World monkeys, while it can cause severe illness in New World monkeys [4]. Scientists think the high susceptibility may be related to the lack of co-evolution with the virus [5]. Yellow fever has been eradicated from Nicaragua since 1954 [6]. However, between 2007 and 2008, Northeastern Argentina faced a major yellow fever outbreak that led to the death of 59 howler monkeys. This yellow fever outbreak held significance to public health research because it emphasized the interconnectedness between human and animal health [5]. Zika virus, also newly introduced to Americas, was first detected in a feverish rhesus monkey, a species of Old World monkeys, in Uganda in 1947 [7]. Further research regarding susceptibility of New World wild animals to Zika virus will help both conservation of wild life and future public health strategy to fight against Zika virus. 

Paso Pacifico is now working with scientists at University of California at Davis to determine the cause of death for the howler monkeys in Nicaragua. [1]. If the link to Zika and the death of howler monkeys in Nicaragua is confirmed, it could be a sentinel signal or precursor to the spread of disease in humans. What experts are hoping to determine is how Zika virus could affect the species or other potential determinants of the unusual die-off of the monkey.

The World Health Organization declared Zika virus a Public Health Emergency of International Concern on February 1st, 2016. On Wednesday, February 17th, 2016 the WHO released a Strategic Response Framework for the spread of Zika virus [8,9].

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Sources

1. http://www.pri.org/stories/2016-02-11/theres-monkey-die-underway-central-america-and-scientists-are-concerned-it-may-be

2. http://animals.nationalgeographic.com/animals/mammals/howler-monkey/

3. http://www.globalpost.com/article/6731008/2016/02/09/experts-investigate-zika-link-mystery-monkey-deaths

4. http://c.ymcdn.com/sites/www.aazv.org/resource/resmgr/IDM/IDM_Yellow_Fever_2013.pdf

5. http://www.sciencedaily.com/releases/2010/03/100311175131.htm

6. http://www.who.int/csr/resources/publications/surveillance/Yellow_fever.pdf

7. http://foreignpolicy.com/2016/01/28/the-zika-virus-isnt-just-an-epidemic-its-here-to-stay-world-health-organization/

8. http://www.infectioncontroltoday.com/news/2016/02/who-announces-global-emergency-response-plan-for-zika-outbreak.aspx

9. http://www.who.int/emergencies/zika-virus/strategic-response-framework.pdf?ua=1

Valley Fever is a disease that is becoming all too common in parts of the Southwest United States such as Arizona and California. This disease, which is gaining notoriety among residents and visitors to these states, is spread through the dust that is a hallmark of this region. The disease-causing spores that are spread via dust are highly sensitive to slight changes in the weather (1,2). It is predicted that this year’s unique weather patterns caused by El Niño will greatly influence the number of Valley Fever cases diagnosed in the area.

What is Valley Fever?

Valley Fever is also sometimes known as coccidioidal granuloma, desert fever, desert rheumatism and San Joaquin Valley Fever (1). Valley Fever is a caused by the spores of fungus Coccidioides, which can be found in the soil and dust of desert regions across North, Central, and South America (1,2). Within the United States, this fungus has been found in southwestern states such as Arizona, California, Nevada, New Mexico, Texas, and Utah (3,4). Recently, the species of Coccidioides that causes Valley Fever have even been found as far north as Washington State (5,6).

Symptoms and Treatment

The most common way for someone to contract Valley Fever is through the inhalation of airborne Coccidioides spores (3). Although it is possible for people to become infected in other ways, these routes of exposure are extremely rare. Some examples of alternative routes of transmission include: infection following transplant of an infected organ, inhalation of spores from an infected wound, and direct contact with objects that have been contaminated with Coccidioides spores (3). Valley Fever often manifests itself with mild symptoms such as general malaise, often resembling those of the flu (7). However, approximately 40 percent of people who are infected do not show any symptoms (8). In rare cases, if the initial infection fails to resolve on its own or is not treated, it can progress to chronic or disseminated Valley Fever (7,8).

Because severity of infection varies widely among individuals, treatment is not always indicated. Patients who exhibit early signs of infection often do not need any antifungal therapy since the infection tends to resolve on its own (4). Conversely, patients who show signs of severe pneumonia soon after infection tend to require antifungal therapy (4). Those who develop chronic pulmonary or disseminated disease, especially those who are immunocompromised, can require prolonged and potentially lifelong antifungal therapy (4).

Who is at Risk?

The CDC notes that the following risk factors put an individual at potentially increased risk of Valley Fever: over the age of 60, immunocompromised, pregnant, diabetic or of Black or Filipino ethnicity may be at higher risk of contracting the more severe forms of Valley Fever (7). Those who live in, or are traveling to, the areas where the fungus is commonly found are also at increased risk of infection. Since 1998, there has been a steady increase in the number of cases reported, but this may be a result of environmental factors, an increase in the number of susceptible people exposed or an artifactual change in the reporting mechanisms (6).

Valley Fever with Respect to El Niño?

El Niño Southern Oscillation is a cyclical climate anomaly that occurs when there are above-average surface temperatures in certain parts of the Pacific Ocean (9). This increase in sea surface water temperatures then can influence worldwide rainfall totals, wind strength, and wind direction. During an El Niño season, the winds that normally blow from east to west along the equator weaken and can sometimes even change direction (9). This change in weather patterns can affect the rates of certain diseases, such as Valley Fever. It has been suggested that an increase in rainfall in the wintertime or in the off-season is directly proportional to an increased number of spores in the environment during the dry season—the period at which most people become infected due to the dustier and drier conditions (10, 11). Given the spores sensitivity to climate change, both weather and health experts have expressed heightened interest in documenting rates of Valley Fever with regards to this year’s particularly strong El Niño. In states such as Arizona, there is increasing concern surrounding the potential spike in cases since 65% of nationally reported Valley Fever cases have occurred within the state (12,11).

As of right now, there is no telling how El Niño will affect the incidence of Valley Fever and the dispersion of the disease-causing spores. The number of cases of Valley Fever could very well change as a result of these disturbances in atmospheric circulation. It is unclear whether heightened clinical awareness, changes in reporting, or a true increase in the number of cases will be observed. However, it is apparent that additional research on this topic is necessary to understand just how Valley Fever is affected by seasonal weather changes (12).

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 Sources

1. Ohio Department of Public Health. (2015). Coccidioidomycosis. Retrieved from http://www.odh.ohio.gov/pdf/idcm/coccid.pdf

2. Sharpton TJ et al., Comparative genomic analyses of the human fungal pathogens Coccidioides and their relatives. Genome Res, 2009 Aug 28;19(10):1722-31.

3. Centers for Disease Control and Prevention. (2016). Sources of valley fever (Coccidioidomycosis). Retrieved from http://www.cdc.gov/fungal/diseases/coccidioidomycosis/causes.html#one

4.  Galgiani, J. N., Ampel, N. M., Blair, J. E., Catanzaro, A., Johnson, R. H., Stevens, D. A., & Williams, P. L. (2005). Https://cid.oxfordjournals.org/content/41/9/1217.full#cited-by. Oxford Journal,41(9), 1217-1223. Retrieved from https://cid.oxfordjournals.org/content/41/9/1217.full#cited-by.

5. Marsden-Haug N, Goldoft M, Ralston C, Limaye AP, Chua J, Hill H, et al. Coccidioidomycosis acquired in Washington State. Clin Infect Dis. 2013 Mar;56(6):847-50.)

6. Centers for Disease Control and Prevention. (n.d.) Valley fever and the expanding geographical range of Coccidioides. Retrieved from http://www.cdc.gov/fungal/pdf/valley-fever-expanding-cocci-508c.pdf

7.  Centers for Disease Control and Prevention. (2014). Ten things to know about valley fever. Retrieved from http://www.cdc.gov/features/valley-fever-10-things/

8.  Valley fever. (n.d.). Retrieved from http://www.mayoclinic.org/diseases-conditions/valley-fever/basics/sympto...

9. L'Heuruex, M. (n.d.). What is the El Niño–southern oscillation (ENSO) in a nutshell? NOAA Climate.gov. Retrieved from https://www.climate.gov/news-features/blogs/enso/what-el-niño–souther...

10.  Hauser, A. (n.d.). Is It Valley Fever? 8 symptoms you should know. Retrieved February 18, 2016, from https://weather.com/health/news/valley-fever-symptoms

11. Tamerius, J. D., & Comrie, A. C. (2011). Coccidioidomycosis incidence in Arizona predicted by seasonal precipitation. PLoS ONE,6(6). Retrieved from http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0021009

12. Marroquin, A. (n.d.). El Niño could cause spike in Arizona valley fever cases. Retrieved February 18, 2016, from http://www.azcentral.com/story/news/local/arizona/2016/01/29/httpcronkit...

Since December 5, 2015, a Yellow fever outbreak in Angola has claimed 125 lives, with 664 suspected cases [1, 2]. The municipality of Viana in Luanda Province is the hot spot of this outbreak, with 173 suspected cases and 29 deaths. The last yellow fever outbreak in Angola occurred in 1986, but poor sanitation, low vaccination coverage and high population density in urban areas may have contributed to and exacerbated the scale of this outbreak [1, 3, 4].

Yellow fever is a mosquito-borne disease caused by yellow fever virus, part of the genus flavivirus [4]. The main vector of the disease is the Aedes aegypti mosquito, which is also responsible for transmission of Zika virus, dengue and chikungunya [5]. There are 44 countries that are considered to be endemic, including 31 countries in Africa and 13 countries in Latin America. There are an estimated 44,000 deaths and 130,000 cases of yellow fever occur annually [4].

Early symptoms of yellow fever include fever, muscle pain, chills, decreased appetite, nausea, and vomiting [4]. In severe cases of yellow fever, patients develop high fever, hemorrhage, jaundice, and renal failure [4]. Approximately 50% of severe yellow fever cases die within 10 to 14 days [4]. There remains no specific treatment for yellow fever virus and treatment given is often palliative [2]. However, there exist effective vaccines against yellow fever. A single dose of yellow fever vaccine provides life-long protection and is considered the most important and effective preventive method [2, 4]. According to the World Health Organization, the vaccination coverage of population at risk in affected regions must be at least 60 to 80% to effectively prevent outbreaks [4].

Authorities in Angola have launched programs in response to the current outbreak. In addition to raising public awareness and improving vector control, a massive vaccination campaign was initiated in early February [6]. The current primary task is to immunize nearly 1.7 million people across Viana [6]. The vaccination campaign will expand to cover other areas in the future [6]. This outbreak may be an opportunity to boost immunization coverage of the population at risk to prevent future outbreaks in the region.     

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Sources

1. http://www.africanews.com/2016/02/27/angola-yellow-fever-death-toll-rises-to-125/

2. http://who.int/csr/don/12-february-2016-yellow-fever-angola/en/

3. http://www.reuters.com/article/us-angola-health-idUSKCN0VO0UJ

4. http://www.who.int/mediacentre/factsheets/fs100/en/

5. http://www.cdc.gov/dengue/resources/30Jan2012/aegyptifactsheet.pdf

6.http://www.afro.who.int/en/media-centre/afro-feature/item/8318-angola-st...

The Lagos State Government confirmed on 22 February that measles was responsible for an outbreak of Febrile Rash Illness (FRI) in southwestern Nigeria. The outbreak began in January 2016 and resulted in the deaths of over 20 children in the Ikate, Lekke area of Lagos [1]. A second outbreak, responsible for 23 deaths and over 300 cases [2], was reported on February 25 in the state of Sokoto, in the north of the country.

According to Lagos state Commissioner for Health, Dr. Jide Idris, children from the affected communities had not been immunized against measles during the state’s recent vaccination campaign. Mass emigration into Lagos state has made it difficult for the government to keep track of all communities in need of health services, leading to some of these communities being overlooked and under vaccinated. He also stated that malnutrition in the area likely played a role in the severity of symptoms in the infected children [3]. Dr. Sani Labaran, Executive Secretary of Sokoto’s Primary Healthcare Development Agency, attributed the outbreak in his state to the parents of affected children rejecting immunization over the past three years, and likewise expressed the importance of proper nutrition [4].

Measles is a highly contagious disease caused by infection with the measles virus, which belongs to the paramyxovirus family, and is spread through the air or through direct contact with infected individuals. Its symptoms are typically mild, and most commonly include a fever and a widespread skin rash that occurs about 14 days after exposure to the virus. Symptoms generally last for five to six days. However, the virus can result in serious complications in certain vulnerable populations, such as blindness, encephalitis, and pneumonia. Malnourished children, as well as those with compromised immune systems, are the groups at greatest risk of experiencing severe measles. While measles has a relatively low fatality rate overall, up to 10% of cases can result in death in areas lacking adequate health care, which results in higher death rates occurring in developing countries [5].

An effective vaccine against measles virus infection was first introduced in 1963, and widespread vaccination campaigns have lead to a 78% decrease in worldwide cases of the disease since 2000. Despite the success of these campaigns, there are still 20 million cases of measles worldwide each year, with 95% of deaths occurring in countries with weak health infrastructures [6]. There is a need to ensure that all communities are accounted for during immunization exercises to prevent future outbreaks and child deaths. Currently, the Sokoto government is working toward improving vaccine efficacy by providing access to cold storages for rural areas so that the vaccines can be properly refrigerated. They have also been leading enlightenment campaigns and working closely with religious and traditional leaders in the area in order to decrease skepticism about the safety and efficacy of vaccines among parents [7].

1. http://www.news24.com.ng/National/News/lagos-confirms-death-of-20-children-from-measles-20160223
2. http://saharareporters.com/2016/02/25/measles-outbreak-leaves-23-children-dead-sokoto-state
3. http://allafrica.com/stories/201602260760.html
4. http://allafrica.com/stories/201602230354.html
5. http://www.who.int/mediacentre/factsheets/fs286/en/
6. http://www.who.int/immunization/topics/measles/en/
7. http://www.premiumtimesng.com/regional/nwest/199221-sokoto-announces-imm...

Lassa fever is endemic to Nigeria, with annual spikes in disease incidence occurring between December and February (6). Since August 2015, there have been 175 reported cases and 101 deaths across Nigeria (9). In Nigeria, the four states being significantly affected by this disease are Bauchi, Edo, Oyo and Taraba (6). The ongoing outbreak is comparable in size to an outbreak in 2012, which resulted in 397 suspected cases, 87 confirmed cases and 40 deaths (12). In the wake of the current outbreak, and as a means of disease prevention, it is reported that Nigerians are stocking up on rat poison, although the Minister of Health promotes the use of traps instead (10,11). The WHO notes that extensive contact tracing is underway, with no contacts having contracted the disease as of January 25 (6).

All About Lassa Fever

Lassa fever is a zoonotic (or animal-borne) acute viral illness that is endemic to areas of West Africa (1). This illness was first discovered in 1969 and was named after the town in Nigeria where it was first identified and isolated (1). The disease is primary spread through contact with items contaminated with rodent feces. It is endemic among the rodent population in countries such as Nigeria, Sierra Leone, Guinea, and Liberia, where it is known to cause outbreaks on an almost annual basis (1, 6). Currently, Nigeria is experiencing an outbreak of Lassa fever and many states are struggling to halt the spread of the virus (6, 10).

Epidemiology of Lassa Fever

The natural host of Lassa fever is a rodent called the multimammate rat (2, 7, 8). This rodent is populous in the savannahs and forests of West Africa, but may also live in human homes and locations where food is stored (2). These rodents breed frequently and produce large numbers of offspring, making them perfect for spreading the virus efficiently (2). Once a rodent is infected with Lassa virus, it excretes the virus through urine and feces for an extended period of time—and sometimes even for the rest of its life (2). The virus can then be transmitted to humans through the inhalation or ingestion of dust particles containing the virus (2, 7). Due to proximity of the rodents to humans, the zoonotic transmission of the virus happens relatively frequently (2). The annual incidence of Lassa fever across this region is estimated to be as high as 300,000 cases, and 5,000 deaths (7).

Infection via contact often occurs after touching objects soiled with infected rodent excretions, eating contaminated food, and the virus entering the body through open cuts and wounds (2). Airborne transmission of the virus can occur during cleaning activities that disperse the viral particles into the air, such as sweeping the fecal matter of an infected rodent (2). 

Lassa virus can also be transmitted between humans when a person comes into contact with the blood, tissue, secretions, or excretions of another individual infected with the virus (2). It is important to note that Lassa virus is not transmitted through skin-to-skin contact and is only transmitted through the exchange of bodily fluids with an already-infected individual (2). Person-to-person transmission in endemic regions is common in healthcare settings, such as hospitals and clinics. This nosocomial spread of the virus can occur through contaminated medical equipment in resource-limited settings where proper infection-control techniques are not always practiced (2).

Signs, Symptoms, and Treatment

For approximately 80% of Lassa virus infections, symptoms are mild and frequently go undiagnosed (3). These mild febrile symptoms usually include a slight fever, general malaise, weakness, and headache (3). More serious symptoms, including hemorrhage, respiratory distress, vomiting, facial swelling, chest pain, back pain, abdomen pain, and shock, are experienced in the remaining 20% of infected individuals. Neurological issues, such as deafness, tremors, and encephalitis, have also been reported (3). Of these neurological complications, deafness is the most common and occurs in one-third of symptomatic infections (3). In many cases, the deafness is permanent (3).

Most symptoms do not appear until one to three weeks after initial exposure (3). For serious infections, death due to multi-organ failure can occur within two weeks after the onset of severe symptoms (3). Only 1% of all Lassa fever virus infections result in death, but the proportion of deaths is much higher among those hospitalized for Lassa fever (3,8). Historically, there have been outbreaks of Lassa fever where the case-fatality rates reached 50% in hospitalized patients (3).

The only available treatment for Lassa fever is ribavirin, an antiviral (4). It has been shown to be most effective when given to infected individuals early in the course of the illness and in conjunction with supportive care(8,4). There are currently no vaccines available to prevent Lassa fever (4).

Prevention

In order to quell the spread of Lassa fever, it is advised that people engage in practices such as using rodent-proof containers to store food and keeping their homes clean to deter rodents (5). These practices, along with other easily implemented changes, can help prevent the zoonotic transmission of the virus. If individuals do become infected with the virus, efforts can be taken to prevent human-to-human transmission in hospital settings as well. These precautions include wearing protective equipment around infected individuals such as masks, gloves, gowns, and goggles and other sanitation techniques (5).

Lassa Fever can be easily prevented. Further precautions need to be taken in order to control the recent outbreak in Nigeria and prevent future outbreaks from occurring. By taking these precautions, Nigeria could help it from spreading to others and prevent more deaths caused by the virus.

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Sources:

1.    Center for Disease Control.  Lassa Fever. (2015). Retrieved March 01, 2016, from http://www.cdc.gov/vhf/lassa/

2.      Center for Disease Control. Lassa Fever: Transmission. (2014). Retrieved March 01, 2016, from http://www.cdc.gov/vhf/lassa/transmission/index.html

3.      Center for Disease Control. Lassa Fever: Signs and Symptoms. (2014). Retrieved March 01, 2016, from http://www.cdc.gov/vhf/lassa/symptoms/index.html

4.     Center for Disease Control. Lassa Fever: Treatment. (2014). Retrieved March 01, 2016, from http://www.cdc.gov/vhf/lassa/treatment/index.html

5.     Center for Disease Control. Lassa Fever: Prevention. (2014). Retrieved March 01, 2016, from http://www.cdc.gov/vhf/lassa/prevention/index.html

6. World Health Organization. Lassa Fever – Nigeria. (n.d.). Retrieved March 01, 2016, from http://www.who.int/csr/don/27-january-2016-lassa-fever-nigeria/en/

7. Lassa Fever. (n.d.). Retrieved March 01, 2016, from http://vhfc.org/lassa_fever

8. Center for Disease Control. Lassa Fever Fact Sheet. (n.d.). Retrieved March 1, 2016, from http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/Fact_Sheets/Lassa_Fe...

9.  Bhadelia, Nahid et al. “Zika isn’t the only outbreak. Nigeria struggles to rein in Lassa Fever”. NPR. Retrieved March 7, 2016, from http://www.npr.org/sections/goatsandsoda/2016/03/04/468955167/zika-isnt-...

10.  NAN (n.d.). Preventing Lassa fever infection in Nigeria. The Guardian. Retrieved March 1, 2016, from http://www.ngrguardiannews.com/2016/01/preventing-lassa-fever-infection-...

11.  Rat poison sales soar as Nigeria fears spread of Lassa fever. (2016, January 25). The Guardian. Retrieved March 1, 2016, from http://www.theguardian.com/global-development/2016/jan/25/rat-poison-sal...

12. Tomasulo, A. (n.d.). Lassa Fever Spreads Through Nigeria. HealthMap. Retrieved March 1, 2016, from http://www.healthmap.org/site/diseasedaily/article/lassa-fever-spreads-t...

The World Health Organization (WHO) has recorded 1,644 laboratory-confirmed cases and at least 590 deaths of Middle East respiratory syndrome coronavirus (MERS-CoV) in 26 countries since its identification in September 2012 [6]. The virus appears to primarily circulate in Saudi Arabia, as the country’s ministry of health has been notified of 1,326 confirmed cases (20 cases under care and 747 recovered) and 559 deaths since 2012 [1]. Around April of 2013 and 2014, the country has encountered sudden increases in the number of MERS patients and it was not clear why the spikes in cases occurred [7]. Even though the pattern did not apply during the same period in 2015, there was a hospital-based outbreak in Riyadh, Saudi Arabia in June through August of 2015 that resulted in 130 patients becoming infected and 51 of which resulted in death [8]. As of 2016, new MERS-CoV clusters are confirmed on a daily basis in Saudi Arabia, confirming approximately 34 cases and 8 deaths [1]. Close contact with confirmed/suspected cases and exposure to camels are often defined as the probable sources of infection for those clusters.

Although MERS-CoV case counts continue to rise slowly but steadily, no specific treatment is currently available.

A group of researchers at Naval Medical Research Center in Maryland, lead by LtCdr. Gabriel Defang, has used bioengineered cows to produce a large quantity of human polyclonal antibodies that have effectively protected lab mice from MERS-CoV virus infection. The researchers introduced two experimental vaccines against the virus, one of which was SAB-301 [4]. They administered SAB-301 to cows whose immunoglobulin genes – that produce antibodies – have been replaced with an artificial chromosome carrying the human immunoglobulin genes. The genetically modified cows developed a robust immune response, and produced large quantities of human polyclonal antibodies against MERS [2]. A single dose of SAB-301 also effectively protected lab mice from the virus either 12 hours before or 24 and 48 hours after MERS-CoV infection. The finding could be a crucial step toward the search for prevention and treatment of the disease. Currently, Defang’s team are taking steps to initiate phase I studies in humans [2,3].

Meanwhile, the Walter Reed Army Institute of Research (WRAIR), GeneOne Life Science Inc., and Inovio Pharmaceuticals, has begun to test their version of MERS vaccine on seventy-five participants in Maryland [5]. This is the first vaccine candidate to be tested in humans. In early 2015, GeneOne and Inovio Pharmaceuticals' DNA-based vaccine for MERS, GLS-5300, proved to be capable of protecting mice, camels, and monkeys from the virus. The vaccine completely freed all vaccinated lab monkeys in the study from MERS symptoms when the animals were challenged with a live MERS virus. Observing the impact of the large scale MERS outbreak in South Korean and its increasing threat to military operations, the WRAIR pledged to advance promising MERS vaccine candidates into human trials and took the opportunity to test GLS-5300 at its Clinical Trials Center [9].

References:

1. Saudi Arabia's Ministry of Health. March 7, 2016 http://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2016-03-07-0...
2. Costandi, Moheb. Neutralizing MERS-CoV through human genes in cows. Nature Middle East. Feb 28, 2016. http://www.natureasia.com/en/nmiddleeast/article/10.1038/nmiddleeast.2016.20
3. Luke, T., et al. Human polyclonal immunoglobulin G from transchromosomic bovines inhibits MERS-CoV in vivo. Sci. Trans. Med. 2016 http://stm.sciencemag.org/content/8/326/326ra21
4. Frey, K. G., et al. Full-Genome Sequence of Human Betacoronavirus 2c Jordan-N3/2012 after Serial Passage in Mammalian Cells. Genome Announc. 2014 http://genomea.asm.org/content/2/3/e00324-14
5. First-in-man trial of MERS vaccine begins. Medical Express. Feb 17, 2016 http://medicalxpress.com/news/2016-02-first-in-man-trial-mers-vaccine.html
6. Middle East respiratory syndrome coronavirus (MERS-CoV) - Saudi Arabia. World Health Organization. Feb 29, 2016 http://www.who.int/csr/don/29-february-2016-mers-saudi-arabia/en/
7. Lakhani, Leone. Saudi officials see spike in MERS coronavirus cases. CNN. April 22, 2014 http://www.cnn.com/2014/04/21/health/mers-coronavirus-saudi-arabia/index.html
8. Wappes, Jim. Saudi Arabia confirms MERS case as report details 2015 outbreak. Center for Infectious Disease Research and Policy. Feb 19, 2016 http://www.cidrap.umn.edu/news-perspective/2016/02/saudi-arabia-confirms-mers-case-report-details-2015-outbreak
9. GeneOne Life Science and the Walter Reed Army Institute of Research Partner to Develop MERS Vaccine. GlobeNewswire. November 10, 2015 http://www.globenewswire.com/news-release/2015/11/19/788811/0/en/GeneOne...

A 31-year old Montevideo resident went to the hospital on February 9, 2016 after experiencing fever and joint pain – two classic symptoms of Dengue fever [1-5, 8]. The patient had no recent travel history outside of Uruguay and tested positive for Dengue Serotype 1 (DEN-1), thereby becoming the country’s first autochthonous - locally transmitted - case [7-9].

Located in South America, Uruguay was one of the few countries in the region where Dengue had not become prevalent [6]. Yet, as of March 10, 2016, one month after the first confirmed case, there have been 570 suspected and 17 confirmed cases of Dengue fever in Uruguay [7, 9]. The majority of these cases have occurred in Montevideo, which is home to 1.5 million people, roughly half of the country’s population [9]. The remaining cases have occurred in Canelones and Salto [9].

What is Dengue?

Dengue fever is a viral disease transmitted to humans through the bite of an infected female Anopheles mosquito [1-5]. Dengue can be found in tropical and sub-tropical climates across the globe, primarily in urban and semi-urban areas [5]. This places about half of the world’s population at risk [5]. The incubation period – the time between exposure to a pathogen and the appearance of symptoms - for Dengue fever is 4 to 10 days [5]. Symptoms last about 2 to 7 days and include: high fever, severe headache, pain behind the eyes, muscle and joint pain, nausea, vomiting, and swollen glands [1-5].

Since there is currently no specific treatment or vaccine against Dengue, vector control is the most effective prevention method [5]. The primary Dengue vector in South America is the Aedes aegypti mosquito [2,5]. The Aedes aegypti mosquito is also capable of transmitting Yellow Fever, Chikungunya, and Zika virus [2]. Although these diseases are also common in the region, there have been no cases in Uruguay thus far [6]. These mosquitoes are daytime feeders that prefer urban habitats, bite multiple humans during each feeding period, and breed primarily in man-made containers such as water tanks, plastic bottles, discarded tires, and flower pots [1-2,5]. An infected mosquito is capable of transmitting the virus for the remainder of its life [5].

Uruguay’s Response

The emergence of Dengue in Uruguay implies that an environment favorable for Aedes aegypti mosquito proliferation has emerged [9]. In fact, Aedes aegypti larvae were discovered within the homes of Uruguay’s confirmed cases [6]. Health officials found larvae in household items such as flower pots, dressers, and water bowls for pets [6].

Prevention and control of Dengue relies heavily on eliminating Aedes aegypti breeding sites and reducing contact between mosquitoes and humans. Therefore, Uruguay health officials are focusing on strengthening vector control, clinical management, and emergency risk communications [9]. Additionally, an aid team consisting of an epidemiologist, entomologist, and risk communication specialist, has been dispatched to Uruguay [9]. Neighborhoods within Montevideo have been fumigated and public service announcements have instructed individuals to eradicate standing water sites within their households [6]. Furthermore, the public has been advised to avoid mosquito bites by regularly using repellents and wearing light colored, long sleeved shirts, as well as pants [9]. Since the Aedes aegypti mosquito is active during the day, young children, or any other individuals who sleep during the day, are encouraged to use mosquito bed nets [9].

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Sources

1. http://www.bbc.com/news/world-latin-america 32589268#sthash.csLVq56t.dpuf
2. http://www.wsj.com/articles/drought-stricken-sao-paulo-battles-dengue-fever-outbreak-1425420508#sthash.csLVq56t.dpuf
3. http://outbreaknewstoday.com/dengue-cases-rise-in-brazil-as-does-dengue-spending-90861/#sthash.csLVq56t.dpuf
4. http://www.wsj.com/articles/brazil-city-calls-in-army-to-fight-dengue-1429292950#sthash.csLVq56t.dpuf
5. http://www.who.int/mediacentre/factsheets/fs117/en/#sthash.csLVq56t.dpuf
6. http://latino.foxnews.com/latino/news/2016/02/28/mosquito-larvae-found-in-uruguayan-houses-infected-with-dengue/
7. http://outbreaknewstoday.com/uruguay-reports-increase-in-dengue-fever-particularly-in-montevideo-64116/
8. http://outbreaknewstoday.com/dengue-fever-uruguays-1st-local-transmission-brazil-tops-100000-cases-in-january-79425/
9. http://www.who.int/csr/don/10-march-2016-dengue-uruguay/en/

Mumps are making a comeback on college campuses nationwide. On Friday, February 25, there were two lab-confirmed cases and three probable cases of mumps reported in New Hampshire [1]. All cases were members of the St. Anselm College hockey team [1]. On the 29th of February, two cases of mumps were diagnosed at Harvard University in Massachusetts. The following week on March 2, Harvard administration reported four additional cases among their student body [2]. On March 14th, the University of San Diego in California reported five mumps cases among their students [9]. Most recently, three cases were confirmed among undergraduate students at Boston University in Massachusetts on March 16th [10].

Symptoms and Spread of Mumps

After initial exposure to the mumps virus, paramyxovirus, it takes around 16-18 days for symptoms to present [1, 3]. However, symptom onset can range from around 12 to 25 days after infection [1, 3]. Not everyone infected with the virus exhibits symptoms and, if symptoms do present, they are often nonspecific. Symptomatic cases generally report: fever, headache, muscle aches, loss of appetite and tender and/or swollen salivary glands [4]. These symptoms often resolve on their own, but in rare instances can cause complications in adults [4]. Serious complications include inflammation of the brain, the tissue covering the brain and spinal cord, ovaries and breasts (in females) and testicles (in males) [4]. Another rare adult complication is deafness [4]. The hallmark of mumps is noticeable swelling of the single or both parotid salivary glands in the cheek and jaw area [3]. This swelling can be differentiated from that of swollen lymph nodes of the neck because instead of swelling in the neck, mumps causes swelling that completely covers the jaw-line and causes the ears to protrude[4]. Mumps is spread through the saliva or mucus of an infected individual, with people often becoming infected through inhalation of the saliva droplets after sneezing or coughing [4,5].

I Thought There Was a Vaccine for That?

Mumps is a vaccine-preventable disease that most of us are vaccinated against. The Centers for Disease Control and Prevention (CDC) advises that all infants be vaccinated with a combination vaccine (MMR) 12 to 15 months after birth, and with a booster at 4 to 6 years of age [6]. Nevertheless, these are just guidelines, as immunizations that are required for enrollment and attendance at a child care facility or school are established and enforced at the state level. After completion of the two-dose series, the vaccine is estimated to be approximately 88 percent effective [1]. Now, some of you may be asking, “Doesn’t vaccination mean that I’m protected?” Unfortunately, vaccination doesn’t guarantee that a sufficient immune response, and therefore protection, is triggered. In other words, just because you are vaccinated doesn’t mean that you will be fully immune from infection.

In New Hampshire, there is no law requiring vaccines prior to entering college. Each college or university is permitted to establish their own rules surrounding required immunizations prior to enrollment at a given institution [7]. On the other hand, in the state of Massachusetts there are established laws regarding immunization for college and university students. In Massachusetts, all health science and full-time students are required to have two documented doses of the MMR vaccine [8]. As shown by the differences between regulations in these two states, vaccination laws for college-age students vary on a state-by-state basis.

For additional information on the MMR vaccine and what this means for mumps in the future, please read:

http://www.healthmap.org/site/diseasedaily/article/just-vax-please-mumps...

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 Sources

1.   Tranchemon, C. (2016, February 27). Health and human services warns of college campus mumps outbreak. WCVB NewsCenter 5. Retrieved March 14, 2016, from http://www.wcvb.com/news/health-and-human-services-warns-of-college-camp...

2.  Freyer, F. J. (2016, March 3). Four more Harvard students get mumps. Boston Globe. Retrieved March 14, 2016, from https://www.bostonglobe.com/metro/2016/03/02/four-more-harvard-students-...

3.  Center for Disease Control. Mumps: For Healthcare Providers. (2016). Retrieved March 14, 2016, from http://www.cdc.gov/mumps/hcp.html#virus

4.  Center for Disease Control. Transmission of Mumps. (2015). Retrieved March 14, 2016, from http://www.cdc.gov/mumps/about/transmission.html

5.  Mayo Clinic. Diseases and Conditions: Mumps. (2015, August 12). Retrieved March 14, 2016, from http://www.mayoclinic.org/diseases-conditions/mumps/basics/causes/con-20...

6.  Center for Disease Control. For Parents: Vaccines for Your Children. (2012). Retrieved March 14, 2016, from http://www.cdc.gov/vaccines/parents/record-reqs/immuniz-records-child.html

7.  National Vaccine Information Center. New Hampshire State Vaccine Requirements. (2016, January 22). Retrieved March 14, 2016, from http://www.nvic.org/vaccine-laws/state-vaccine-requirements/new-hampshir...

8.  Massachusetts Department of Public Health. Massachusetts School Immunization Requirements for School Year 2015-2016. (n.d.). Retrieved March 14, 2016, from http://www.mass.gov/eohhs/docs/dph/cdc/immunization/guidelines-ma-school...

9. University of San Diego reports five mumps cases. (2016, March 14). Outbreak News Today. Retrieved March 16, 2016, from http://outbreaknewstoday.com/university-of-san-diego-reports-five-mumps-...

10. Brown, J. (2016, March 16). Three Mumps Cases Found at BU. BU Today. Retrieved March 16, 2016, from http://www.bu.edu/today/2016/cases-of-mumps/

A mysterious outbreak of an extremely rare bloodstream infection has been ongoing in Wisconsin for at least four months, and public health officials are unsure of the cause. The Wisconsin Department of Health has reported that 54 cases of Elizabethkingia anophelis infection have occurred since 1 November 2015. Elizabethkingia, an opportunistic pathogen that is abundant in the environment, has caused infections in at least 12 counties throughout the state and has been identified to be linked primarily to healthcare facilities. Symptoms of Elizabethkingia infection include fever, shortness of breath, and cellulitis [1]. The majority of cases during this outbreak have been in patients over the age of 65, and all cases have had previously diagnosed underlying illnesses [2]. To date, 17 deaths have been associated with the outbreak [1], and a case has also been confirmed in western Michigan [3].

The outbreak has created unique challenges for the Centers for Disease Control and Prevention (CDC) and for local health departments. In the past, infections from the bacteria had been so rare that they were not closely monitored, making it difficult to determine how many people are usually affected [2]. Wisconsin typically only sees one or two cases per year according to University of Wisconsin infection control director Dr. Nasia Safdar. The CDC laboratory in Atlanta is currently the only laboratory in the United States that can distinguish E. anophelis from a different, more common species in the same genus, E. meningoseptica. Thus, samples often need to be sent to the CDC lab before cases can be officially confirmed [4].

At this point, the source of the unprecedented spread of the bacteria is unknown, making it difficult for health departments to prevent future infections. Five CDC “disease detectives” have been sent to Wisconsin for an investigation of the outbreak, which will involve reviewing medical records and interviewing patients to determine if a connection exists between the cases [5]. Exposure from contaminated food and water had been identified as a potential risk factor, since the bacteria is so widely present in the environment. However, the water supply has been ruled out as a potential source of the infection after it tested negative for the presence of Elizabethkingia. No pattern of medical treatment or device usage has emerged among the cases, so it is not clear if a relationship exists between infection and specific type of treatment [4].

Another problem presented by Elizabethkingia anophelis is that it is difficult to treat with antibiotics [6]. However, despite its multi-drug resistance, Elizabethkingia is not considered a true “superbug” as Wisconsin health officials have identified antibiotics to which the bacteria are susceptible. Dr. Safdar has said that the general public should not be concerned about the bacteria as it causes disease only in the small proportion of the population with compromised immune systems. Elizabethkingia is not known to be spread from person to person, and infection is believed to occur as a result of contact with contaminated medical equipment, though this has not been confirmed. Control of the outbreak will rely on diligent reporting from healthcare workers as well as the investigative efforts by public health officials [4]. A rapid identification of cases occurred after the Wisconsin Department of Health Services initially provided guidance to health workers about identifying and reporting cases. This has led to an improvement in outcomes for patients as healthcare workers begin to administer proper treatment [1].

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Sources

1. https://www.dhs.wisconsin.gov/disease/elizabethkingia.htm

2. http://www.wpr.org/crash-course-elizabethkingia-rare-bacterial-infection-spreading-across-wisconsin

3. http://www.mlive.com/news/grand-rapids/index.ssf/2016/03/bacteria_outbreak_in_wisconsin.html

4. http://outbreaknewstoday.com/elizabethkingia-outbreak-what-we-know-so-far-86330/

5. http://outbreaknewstoday.com/elizabethkingia-outbreak-is-very-worrisome-to-cdc-besser-32199/

6. http://time.com/4257603/wisconsin-disease-elderly-elizabethkingia/

The United Nations Children’s Fund has stated that approximately 11 million children in eastern and southern Africa face hunger, disease and water shortage due to this year’s unusually extreme El Niño season [1]. In November, the United Nations warned that the nations in the Horn of Africa, which includes Djitbouti, Eritrea, Ethiopia and Somalia, are at a heightened risk for food insecurity, due to the extreme droughts that have occurred over recent months [2].

Despite concerns from the United Nations, the Eritrean President Isaias Afwerki stated that “the country will not face any crisis in spite of reduced agricultural output” and further, “Isaias praised the government's judicious policy and approaches of bolstering its strategic food reserves” [2].

Interestingly, Eritrea has long been known to reject UN food aid and prefers a policy of self-reliance, with Isaias stating that he was not worried. Consequently, the UN has limited access to the country and many foreign aid agencies are not allowed to operate there [2]. While Eritrea may claim that it will not face food insecurity this year, the surrounding region faces crop reduction by 50-90%. In neighboring Ethiopia, there is upwards of 10 million people in need of food aid, a number that is expected to rise to 18 million by the end of 2016 [2].

In this region, food insecurity and malnutrition have become an even more heightened problem within the last year. The World Food Programme published a report in December 2015 that highlights the expected outcomes and impacts of El Niño across the globe. Most of East Africa has already seen the end of the rainy season and is now dealing with the repercussions of a stunted growing season. Ethiopia faces a major drought emergency and Sudan faces a shortage of rainfall and poor pastor production [3]. The Horn of Africa is expected to experience wetter than average conditions, with flood warnings throughout Kenya and Somalia. However, a benefit of the wet conditions is that the increase in water could help recover pastoral areas [3]. With a warming climate and fluctuations of extreme rains and droughts, El Niño also brings a greater susceptibility to infectious diseases [7]. Wet and warming temperatures are an ideal breeding ground for mosquitos that transmit vector borne diseases such as malaria, dengue, yellow fever and Zika virus as well as waterborne diseases such as cholera. In the last year, Tanzania and Somalia have both experienced major cholera outbreaks, which government officials say have been caused by the pooling of groundwater due to El Niño rains [8,9].

Leila Gharagozloo-Pakkala, UNICEF Regional Director for Eastern and Southern Africa, reports that "the El Niño weather phenomenon will wane, but the cost to children - many who were already living hand-to-mouth - will be felt for years to come. Governments are responding with available resources, but this is an unprecedented situation. Children’s survival is dependent on action taken today" [1].

Malawi is experiencing its worst food crisis in nine years, with approximately 2.8 million people facing hunger (15% of the population). UNICEF cites that from December 2015 to January 2016, cases of "severe acute malnutrition" have more than doubled in Malawi[4].

Due to extreme droughts brought on by El Niño, South Africa has also experienced its driest year in over a century, and will be importing at least half of its required maize crop. Food prices have drastically increased because of reduced production and availability [4].

In response to the emergency situation, many nations have contributed funds to implement food insecurity interventions. Italy, for example, has allocated one million euros between the World Food Programme and the United Nations Food and Agriculture Organization to aid in curbing food insecurity in Ethiopia [5].

Below is a list of the UNICEF humanitarian appeals in El Niño-affected countries [1]:

§  $US 26 million in Angola

§  $US 87 million in Ethiopia

§  $US 3 million in Lesotho

§  $US 11 million in Malawi

§  $US 15 million in Somalia

§  $US 1 million in Swaziland

§  $US 12 million in Zimbabwe

In order to prevent years of production failure, food insecurity and malnutrition, countries across the globe need to raise funds now to protect against the devastating impacts of El Niño. The European Union has allocated 12 million euros to provide food assistance to countries of southern Africa, including Angola, Zimbabwe, Malawi, Swaziland, Lesotho and Madagascar, and allocated an additional five million euros to southern Africa in 2016 to support disaster risk reduction activities and protect against the impact of natural disasters such as drought, floods and cyclones that frequently affect Mozambique, Malawi and Madagascar [6].

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Sources

[1] http://www.unicef.org/media/media_90252.html

[2] http://reliefweb.int/report/eritrea/eritrea-president-dismisses-food-cri...

[3] http://documents.wfp.org/stellent/groups/public/documents/ena/wfp280227.pdf

[4] https://www.rt.com/news/332733-children-malnourished-el-nino/

[5] http://reliefweb.int/report/ethiopia/ethiopia-italy-contribute-1-million...

[6] https://ec.europa.eu/jrc/en/news/el-nino-devastating-impact-southern-afr...

[7] http://www.who.int/globalchange/publications/climatechangechap6.pdf

[8] http://allafrica.com/stories/201512311089.html

[9] http://reliefweb.int/report/united-republic-tanzania/tanzania-cholera-em...

At least five people have died since 29 February 2016 due to a new flare up of Ebola virus disease (EVD) in Guinea [1]. The first two confirmed cases of the virus were detected in the village of Korokpara and involved a mother and her five-year-old son. These are the first cases of Ebola in Guinea since the World Health Organization (WHO) declared the country free of the disease in December 2015. This declaration came two years after an outbreak that began in 2013 killed approximately 2,500 people in Guinea and over 11,000 in West Africa [2]. The WHO had warned that Guinea, as well as the neighboring countries of Liberia and Sierra Leone, are at risk for ongoing smaller outbreaks due to persistence of the virus in some previously infected individuals [3]. Guinea’s 90-day heightened surveillance period was set to end in late March [4].

Ebola virus disease is an often-fatal illness caused by a virus in the Filoviridae family. The first symptoms of the disease can appear 2-21 days after exposure and typically include fatigue, fever, and muscle pain. This is followed by more severe symptoms including vomiting, diarrhea, and, in some cases, internal bleeding and multi-organ failure. The virus is transmitted to human populations through close contact with the bodily secretions of infected animal hosts, such as fruit bats, chimpanzees, gorillas, and forest antelopes [5]. This typically happens during the hunting and butchering processes involved with food preparation of “bushmeat” [6]. The virus is also capable of spreading from person-to-person through contact with infected bodily fluids. Many healthcare workers have been infected with Ebola while treating EVD patients, and transmission can occur during burial ceremonies as bodies remain highly infectious even after death [5].

The first outbreak of Ebola occurred in 1976 in Zaire--now the Democratic Republic of the Congo-- where 318 people were infected and 280 (88%) died. Several smaller outbreaks have occurred since then, mostly in Central Africa [7]. High case fatality rates are common during these outbreaks, ranging from 25% to 90% with an average of about 50% [5]. In March 2014, an outbreak of febrile illness in Guinea that had already killed 59 people was confirmed to be caused by EVD. Further investigation reveled that the first case was a two-year-old child in Guéckédou, Guinea in December 2013. The outbreak spread to Liberia and Sierra Leone and caused mass illness and death in these countries, with additional cases reported in Senegal and Nigeria as well as the United States and Europe [8]. Countries most impacted by EVD have fairly weak health infrastructure, making it difficult for governments to keep the spread of the disease under control. This also contributed to the inability to deliver proper care and isolation for infected individuals. As of 20 March 2016, an estimated 28,644 people have been infected worldwide during this outbreak and 11,320 people have died, making it significantly larger than all previous outbreaks combined [9].

Even though it was declared to be over in December 2015, it is clear that the 2014 outbreak of Ebola continues to impact the most heavily affected countries of Guinea, Sierra Leone, and Liberia. Initial tests performed on the new cases in Guinea suggest that they are part of a previously known transmission chain of the virus. This reveals that the flare up resulted from contact with survivors from the 2014 outbreak in whom the virus had persisted, and it is not believed that the current flare-up was caused by a new introduction of the virus from an animal [10]. A similar flare-up occurred in January 2016 in Sierra Leone, which had been previously declared free of Ebola in November 2015. After 42 disease-free days (two incubation periods) this outbreak was declared over by the WHO on 17 March, the same day that the first case was confirmed in Guinea [11].

Several measures have been taken so far in an attempt to contain the outbreak. The WHO deployed surveillance experts and contact tracers to Guinea on 18 March 2016 after the confirmation of two additional cases and reported that additional personnel would be sent in the coming weeks [4]. So far, the Guinean government has quarantined 816 people because of potential contact with the infected individuals. They will be kept in their homes during the 21-day incubation period of the virus and will be released if they are not exhibiting symptoms after this time [12]. Over 100 of these individuals are considered high-risk for developing the virus [10]. Additionally, Liberia has closed its border with Guinea in response to the outbreak [13]. If the reaction to this current flare-up in Guinea is as swift and effective as it was to the outbreak in Sierra Leone in January, it is likely that this outbreak will be successfully contained. This will require maintaining vigilant surveillance as well as practicing hygiene both at home and in healthcare facilities to prevent transmission of the virus [11].

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Sources

1. http://www.timeslive.co.za/sundaytimes/stnews/international/2016/03/22/At-least-5-dead-in-Guinea-Ebola-flare-up-health-officials

2. http://news.sky.com/story/1662070/two-cases-of-ebola-confirmed-in-guinea

3. http://www.the-scientist.com/?articles.view/articleNo/45630/title/WHO--Ebola-Confirmed-in-Guinea/

4. http://mynews4.com/news/health/who-sends-specialists-in-response-to-guinea-ebola-flare-up

5. http://www.who.int/mediacentre/factsheets/fs103/en/

6. http://www.cdc.gov/vhf/ebola/pdf/bushmeat-and-ebola.pdf

7. http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html

8. http://www.theguardian.com/world/2014/oct/15/ebola-epidemic-2014-timeline

9. http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html

10. http://www.cidrap.umn.edu/news-perspective/2016/03/guinea-ebola-cluster-likely-part-known-transmission-chain

11. http://www.who.int/mediacentre/news/statements/2016/end-flare-ebola-sierra-leone/en/

12. http://www.newsweek.com/ebola-guinea-quarantine-816-people-latest-flare-439376

13. http://www.theguardian.com/world/2016/mar/23/ebola-deaths-in-guinea-prompt-liberia-to-close-border

Currently, there is a particularly worrisome yellow fever outbreak in Angola due to the increasing number of cases, a vaccine shortage, and another simultaneous mosquito-disease epidemic. Angola is experiencing its worst yellow fever outbreak in the last 30 years (1). So far, the yellow fever death toll in Angola has reached 250, with the number of reported cases has reached 1,908 as of April 20th (6, 7). The virus has hit 16 of the 18 provinces in Angola and is continuing to spread to other provinces and countries (1). Imported cases of the virus from Angola have been reported in China, the Democratic Republic of Congo, and Kenya (2).

What is Yellow Fever?

Yellow Fever is mosquito-borne virus that is endemic in tropical areas of Latin America and Africa (5). The virus is transmitted by two types of mosquitoes, the Aedes aegypti and Haemagogus mosquitoes (5). The Aedes aegypti is the same mosquito that transmits Zika virus and dengue fever (2). The mosquitoes contract the virus primarily from monkeys and then are able to transmit the virus to humans (5). “Yellow” in ‘Yellow Fever’ refers to the jaundice that occurs in some patients as a result of the virus (5).

Upon initial infection, the virus incubates in the body for 3-6 days. The virus occurs in two phases -- the first phase is the “acute” phase and causes symptoms of fever, muscle pain, back pain, headache, shivers, lack of appetite, and nausea or vomiting (5). The majority of people affected by the acute phase improve and recover after 3-4 days from the onset of symptoms (5).

However, 15% of infected patients do not improve from the acute phase and enter into the second and more dangerous phase of the virus -- the toxic phase (5). This phase occurs within 24 hours of the initial remission of the virus (5). Common symptoms of the toxic phase include high fever, jaundice, abdominal pain and vomiting, kidney function deterioration, and bleeding from the mouth, nose, eyes, or stomach (5). When this bleeding happens, bloody vomit and feces can also occur (5). Only 50% of patients who reach the toxic phase of the virus survive and those who do not survive, die within 10-14 days (5). Those who are lucky enough to survive can recover without severe organ damage (5).

There is no specialized treatment for Yellow Fever (5). A patient can receive supportive care that treats dehydration, respiratory failure, and fever but this is often not readily available in poorer areas (5). The most important measure to prevent the outbreak of this virus is vaccination (5). The Yellow Fever vaccine has found to be 90% effective in people within 10 days of receiving the vaccination and 99% effective in people within 30 days of receiving the vaccination (5). Mosquito control and epidemic preparedness and response are also necessary methods of control and prevention. However, lack of effective mosquito control and appropriate epidemic preparedness and response have been major contributing factors to the alarming outbreak in Angola.

The Vaccine Shortage

The current outbreak began in the province of Luanda, the capital of Angola and the majority of the cases are still being reported within that area (2). To control this epidemic, Angola’s Ministry of Health and the World Health Organization launched an emergency vaccination campaign in Luanda province in February with plans to vaccinate 6.5 million people (3,4). Vaccination is the best known method of prevention of Yellow Fever and is necessary to stop this continuous outbreak.

However, an extreme shortage of the vaccine has been a major concern for this epidemic. The World Health Organization exhausted its emergency stockpile of the Yellow Fever vaccine and still needed to vaccinate 1.5 million people in Luanda alone (2). Additionally, there are only four facilities globally that produce the yellow fever vaccine (4). These four facilities will be challenged to effectively meet the continuing supply and demand of the vaccines needed to address this outbreak. With the emergency stockpile completely empty, more emphasis on producing the yellow fever vaccine has been prioritized (4). Some studies have shown that using one-fifth or one-tenth of the current vaccination dose may protect people against the disease, which could provide an alternative solution to the vaccine shortage issue (4). The effectiveness of that possible solution remains to be determined, but may be a better alternative for prevention and protection.

Given the recent vaccination shortage and the continuous spread of the virus to other countries, many health experts fear this outbreak will become uncontrollable (4). The virus’ spread to Asia is the most alarming concern because there may not be enough vaccines to treat Angola’s population and other possible outbreaks in Africa and Asia. Vaccine manufacturers are attempting to increase productivity in the making of the vaccine and will continue to ship vaccines where they are needed (2). Additionally, Angola has put a ban on visitors aged 9 months and older allowed into the country without proper vaccination (3). People who wish to travel to Angola during this time must show proof of proper vaccination.

Replenishment of the Emergency Supply

Thankfully, at the end of March 2016, the emergency vaccine supply was replenished to include 10 million vaccines available to prevent yellow fever (6). This new supply will greatly contribute to effectively controlling the further spread of yellow fever in Angola. However, there is still a concern with regards to potential spread in other parts of Africa and Asia and whether further vaccination production, in addition to the replenished supply, should be prioritized.

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Sources

1. Gaffey, C. (2016, April 16). Angola: Yellow Fever Death Toll Rise to 225 Amid Vaccine Shortage. Newsweek. Retrieved April 25, 2016, from http://www.newsweek.com/angola-yellow-fever-death-toll-rise-225-amid-vac...
2. Goldschmidt, D. (2016, March 25). Yellow fever vaccine shortage as outbreak in Angola spreads. CNN. Retrieved April 25, 2016, from http://www.cnn.com/2016/03/25/health/yellow-fever-vaccine-shortage-angola/
3. Yellow Fever in Angola. (n.d.). Retrieved April 25, 2016, from http://wwwnc.cdc.gov/travel/notices/alert/yellow-fever-angola
4. Kupferschmidt, K. (2016). Angolan yellow fever outbreak highlights dangerous vaccine shortage. Science. doi:10.1126/science.aaf4082
5. Yellow fever. (n.d.). Retrieved April 25, 2016, from http://www.who.int/mediacentre/factsheets/fs100/en/
6. Angola' health officials extend vaccination campaign for yellow fever to Huambo and Benguela provinces. (2016, April 21). News Medical. Retrieved April 25, 2016, from http://www.news-medical.net/news/20160421/Angola-health-officials-extend-vaccination-campaign-for-yellow-fever-to-Huambo-and-Benguela-provinces.aspx
7. Yellow fever outbreak in Angola: Vaccination campaigns to extend to Huambo and Benguela provinces. (2016, April 20). Outbreak News Today. Retrieved April 25, 2016, from http://outbreaknewstoday.com/yellow-fever-outbreak-in-angola-vaccination...

Outbreaks of the mysterious bacteria, Elizabethkingia, has been reported in Wisconsin and most recently, in Illinois. Yet, it has recently been discovered that the Elizabethkingia strain in Wisconsin is different than the strain documented in all, but one of the cases, in Illinois (1). As of April 20th, Illinois has reported ten confirmed cases, including six deaths attributed to Elizabethkingia (1). These reported deaths were over the age of 65 and all had unrelated, but severe health complications alongside the infection (1). Therefore, it is unknown whether the cause of these deaths were due to the infection of the bacteria, the underlying health conditions, or a combination of both (1).

Why is this outbreak unusual?

Perhaps the most unusual part of this outbreak is that Elizabethkingia rarely causes infections in humans (1). The bacteria, Elizabethkingia anophelis, is generally found in water sources including rivers, reservoirs, and soils (1). Many of the previously documented infections of Elizabethkingia have occurred within the context of health care facilities but this new cluster of cases in Illinois seems to be occuring within the community (2). However, the means in which individuals have become infected also remains unknown (1).

What is Elizabethkingia?

Elizabethkingia often tends to be a bloodstream infection, but in some cases it has been found to infect other sites such as the respiratory system or joints (3). Diagnoses of cases are conducted through blood tests (4). Symptoms of the infection include fever, shortness of breath, chills, and swelling and redness of the skin (1). The bacterial infection often manifests itself as meningitis in newborns or meningitis, and blood or respiratory infections in immunocompromised adults (1). Elizabethkingia is treatable, however it is resistant to many antibiotics (5). Doctors in this recent outbreak have identified a few antibiotics that have been successful in treating the infection, which include fluoroquinolones, rifampin, and trimethoprim/sulfamethoxazole (5). Hopefully these antibiotics can be used to treat more cases and prevent any additional deaths attributed to this outbreak.

Illinois Response to the Outbreak

The Illinois Department of Public Health is quite busy with determining the source of the outbreak, while also treating the people who have already contracted the infection. The agency is urging health care workers to test anyone who presents with similar symptoms of Elizabethkingia for infection (6). The agency is also trying to establish a link between the confirmed cases while investigating the source of the bacteria, why and how people are getting infected, and the exact effect that the bacteria has on a person’s health (6). Hopefully, Illinois will discover the cause of this outbreak in order to effectively treat and prevent further cases of this bacterial infection.

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Sources

1. Rhodes, D. (2016, April 20). 10 Illinois residents infected with Elizabethkingia. Chicago Tribune. Retrieved April 26, 2016, from http://www.chicagotribune.com/news/local/breaking/ct-elizabethkingia-inf...
2. Meyers, S. L. (2016, March 9). A Crash Course In Elizabethkingia, The Rare Bacterial Infection Spreading Across Wisconsin. Wisconsin Public Radio. Retrieved April 26, 2016, from http://www.wpr.org/crash-course-elizabethkingia-rare-bacterial-infection....
3. Goldschmidt, D. (2016, April 13). Elizabethkingia outbreak spreads; source still a mystery. CNN. Retrieved April 26, 2016, from http://www.cnn.com/2016/04/12/health/elizabethkingia-illinois-bacterial-...
4. Elizabethkingia. (2016). Retrieved April 26, 2016, from http://www.cdc.gov/elizabethkingia/about/index.html
5. Rettner, R. (2016, April 20). 5 Things to Know About Elizabethkingia. Discovery News. Retrieved April 26, 2016, from http://news.discovery.com/human/health/5-things-to-know-about-elizabethk...
6. Bair, D., & Czink, K. (2016, April 20). Concerns grow over Elizabethkingia. WGN Tv. Retrieved April 26, 2016, from http://wgntv.com/2016/04/20/concerns-grow-over-elizabethkingia/

On 23rd of June, Cape Verde’s Ministry of Health reported that there had been 11 cases of Zika virus-linked microcephaly on the small African nation [1].  This count is a significant jump from the previously reported three cases as of the beginning of June [2]. The first case in Cape Verde, confirmed on 15th March in the area of Praia [3], was diagnosed while much about Zika virus and its suspected-to-be-associated microcephaly remained unknown. It was not until the end of March 2016 that the World Health Organization (WHO) announced that there was enough evidence to scientifically link Zika virus and microcephaly in infants exposed to the virus in utero [4]. 

The confirmation of Zika virus-linked microcephaly cases in Cape Verde is of particular importance due to the location and timing of the outbreak. Zika virus outbreaks have been confirmed in African countries since it was serologically confirmed in humans in Uganda in 1948 [5].  The virus was confirmed by serological evidence in multiple locations in Asia, but it was not until 2007 on Yap Island that it was confirmed as a clinical illness outbreak outside of Africa [5]. From there, outbreaks were then confirmed in French Polynesia and other Pacific Islands [6]. Genetic studies of the virus from the affected populations revealed three distinct Zika virus strains or genotypes: one from West Africa, one from East Africa, and one from Asia [6].  Given Cape Verde’s location, 350 miles off the coast of West Africa, there was little debate or speculation as to what strain its outbreak belonged – the focus remained on the 7500 suspected cases in the country and the outbreak swiftly spreading through the Americas. 

Prior to the outbreak in the Americas, Zika virus was considered a ‘nuisance disease’ – causing only a short/mild illness. It was not until the cases of microcephaly, Guillain Barre Syndrome (GBS) and other neurological complication emerged, that the disease became of greater concern [7].  The first cases of GBS appearing in conjunction with Zika virus infection occurred in French Polynesia between 2013 and 2014 [8]. During that outbreak, the largest of its time, 42 patients were diagnosed with GBS – a retrospective case control study provided the evidence necessary to link Zika infection with the neurological condition [8]. 

Genetic sequencing revealed that the strain of Zika virus to blame for the outbreak in the Americas was the Asian strain – closely resembling the virus at its state during the French Polynesian outbreak [9].  The study authors, from the University of California at Los Angeles (UCLA), highlight the dangerous developments in the virus during this outbreak: “We don’t know why Zika infection was not associated with serious human disease, especially in newborns, until recently … We hoped that taking a closer look at the virus’ genetic changes over time would reveal clues to this mystery” [9].  Significant mutations were found, further segregating the Asian strain from the African strains, and mutations have had other effects on its clinical disease. The author of the study explains, “We suspect these mutations could help the virus replicate more efficiently, evade the body’s immune response or invade new tissues that provide a safe harbor for it to spread” [9]. These mutations may explain why the ‘serious human disease’ of the outbreak in the Americas may have suddenly cropped up.  

On 20th of May, it was confirmed that it was Asian strain of Zika virus responsible for the outbreak and cases of microcephaly in Cape Verde – the first time the strain responsible for ‘serious human disease’ has been reported in Africa [10]. This makes sense, given its recent reports of microcephaly – approximately nine months after the first reports of infection, in late September of 2015 [11]. Much uncertainty remains regarding a mother’s Zika virus infection timing and its risk to the unborn fetus – some studies report that there is no risk during the third trimester, others report that there has been a connection to increased rates of sudden miscarriage [12, 13]. Much of these unknowns are a result of the fact that we do not yet know the breadth of the Zika-virus syndrome in newborns exposed in utero. Research now suggests “serious joint problems, seizures, vision impairment, trouble feeding and persistent crying can be added to the list of risks from Zika exposure in the womb” [14]. It may be months or years before we understand all complications, both congenital and developmental, in this cohort of newborns. 

It remains unclear why we are only now seeing these severe outcomes from the Asian strain of the Zika virus. Early findings, published in Nature Immunology, suggest that previous exposure to the vectorborne dengue virus may increase the potency of Zika [15]. The mechanism for this increased potency is suggested to be a result of  “some dengue antibodies can recognize and bind to Zika due to the similarities between the two viruses, but that these antibodies may also amplify Zika infection in a phenomenon called antibody-dependent enhancement” [15]. It is proposed that this may be why this outbreak is resulting in ‘serious human disease’ – it’s occurring in regions previously affected by dengue outbreaks.  

When we think of dengue virus outbreaks – we typically think of Southeast Asia and South America, primarily Brazil. So what about Cape Verde? Does the previous-dengue-infection-exacerbating-Zika-virus theory hold up? In 2009, the Cape Verde Ministry of Health reported over 13,000 suspected cases of dengue [16]. The outbreak was the first dengue outbreak for the country and, at the time, the biggest outbreak recorded in Africa [16]. Given Cape Verde’s previous exposure to dengue, it is plausible that the new theory on Zika virus infection for the current outbreak holds up – and might explain the new cases of microcephaly being reported. Only time will tell what can be done to mitigate risks and outcomes. 

[1] http://www.rtp.pt/noticias/mundo/cabo-verde-regista-11-casos-de-microcef...
[2] http://www.rtp.pt/noticias/mundo/cabo-verde-regista-tres-casos-de-microc...
[3] http://www.rtp.pt/noticias/mundo/cabo-verde-regista-primeiro-caso-de-mic...
[4] http://www.npr.org/sections/thetwo-way/2016/03/31/472607576/health-agenc...
[5] http://wwwnc.cdc.gov/eid/article/15/9/09-0442_article
[6] http://wwwnc.cdc.gov/eid/article/22/5/16-0065_article
[7] http://www.usnews.com/news/politics/articles/2016-04-11/us-officials-the...
[8] http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)00562-6.pdf
[9] http://newsroom.ucla.edu/releases/ucla-scientists-unravel-the-genetic-ev...
[10] http://reliefweb.int/report/cabo-verde/who-confirms-zika-virus-strain-im...
[11] http://www.who.int/csr/don/21-december-2015-zika-cape-verde/en/
[12] http://www.nejm.org/doi/full/10.1056/NEJMoa1604037
[13] http://www.nytimes.com/interactive/2016/health/what-is-zika-virus.html
[14] http://www.scientificamerican.com/article/list-of-possible-zika-birth-de...
[15] http://www.reuters.com/article/us-health-zika-dengue-idUSKCN0Z921O
[16] http://www.doctorswithoutborders.org/news-stories/field-news/cape-verde-...

As of July 1st, 2016, the Ministry of Health in Brazil confirmed that there have been 1,233 deaths linked to the ongoing H1N1 influenza outbreak in the country [1].

By comparison, the years of 2014 and 2015 saw only 163 and 36 deaths from H1N1 influenza, respectively. The vast proportion of the deaths this year has emerged from the region of Sao Paolo, where 517 deaths were reported. Rio Grande do Sul, Brazil’s southernmost state, has the second highest proportion of influenza deaths -- 142. Other strains of influenza have claimed an additional 93 lives in Brazil. Complications from H1N1 infection include severe acute respiratory syndrome (SARS), of which 6,569 have been registered across the country [1]. 

This is the largest outbreak of H1N1 influenza in Brazil since the 2009 pandemic, where the country saw 2,060 deaths from the virus [1].

Rising rates of H1N1 deaths sparked the Ministry of Health in Brazil to conduct a mass vaccination campaign to prevent an influenza outbreak from April 30th to May 20th, which provided free flu shots with the aim to immunize 48.9 million people [5,2]. The typical flu season in Brazil spans during the southern hemisphere’s winter months of May to July. The Ministry of Health reported that the mass vaccination campaign reached 95.5% of its target demographic, which includes young children, pregnant women, women who recently gave birth, and the elderly. It is estimated that a total of 1.7 million people in Sao Paolo were vaccinated against influenza during the vaccination campaign [2,3]. Despite a successful mass vaccination campaign, the H1N1 outbreak has continued to rise, bringing the reported death toll to 1,233 to date.

In April 2016, the BBC reported that there had been 230 deaths due to H1N1 influenza in Brazil [3]. However, rates have significantly increased in recent weeks, with as many as 122 deaths from H1N1 influenza occurring over the course of one week [4]. There is no clear explanation yet as to why this phenomenon is happening, however there is a suspicion that the outbreak could be attributed to increased travel to and from Brazil over the past year [5]. 

Additionally, there remains sparse information regarding this year’s H1N1 outbreak, despite its scale and fatality rate – across both English language media outlets and media outlets within Brazil. There is a severe lack of sources that contain detail about why the H1N1 outbreak is occurring. 

Panama, another Latin American country, has also experienced a major H1N1 outbreak this year, and has declared a national health alert with a reported 22 deaths and 671 hospitalizations from H1N1 influenza infection. This occurred in the midst of Panamanian Health Minister Francisco Javier Terrientes’ resignation [6].

The results of the H1N1 influenza outbreak in Brazil has the potential to impact the 2016 Olympic Games, which will take place in Rio de Janeiro in only a few short weeks. To date, Rio de Janeiro has registered 47 deaths from the H1N1 outbreak [1]. The Center for Disease Control and Prevention recommends all travelers to the Olympic Games be up to date with routine vaccinations, including the influenza vaccine [7].

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Sources

[1]http://g1.globo.com/bemestar/noticia/2016/07/h1n1-ja-matou-1233-pessoas-no-brasil-em-2016-segundo-ministerio.html

[2]http://www.brasil.gov.br/saude/2016/04/campanha-nacional-de-vacinacao-contra-a-gripe-comeca-no-sabado

[3]http://www.bbc.com/news/world-latin-america-36145181

[4]http://outbreaknewstoday.com/brazil-reports-nearly-1000-influenza-deaths-in-first-five-months-sao-paulo-sees-400-h1n1-deaths-42236/

[5]http://www.cctv-america.com/2016/04/14/first-zika-now-a-fatal-h1n1-outbreak-in-brazil

[6]http://outbreaknewstoday.com/panama-h1n1-outbreak-health-minister-terrientes-resigns-as-death-toll-ris

es-44527/​

[7] http://wwwnc.cdc.gov/travel/notices/alert/2016-summer-olympics-rio 

Aedes aegypti in the Americas

Latin America is currently fighting to prevent the diseases transmitted by the Aedes aegypti mosquito: Zika, Dengue, and Chikungunya. There are significant and ongoing outbreaks of these diseases in Latin America, including Brazil, Mexico, Argentina, Peru, and Colombia, to name a few [1-5]. Anyone who has watched the news recently knows that Brazil is the epicenter of the Zika virus outbreak; additionally, dengue is endemic to the country. However, they are not alone - other countries in Latin America are fighting simultaneous outbreaks. Countries in Latin America are taking a variety of approaches to fight and prevent A. aegypti from proliferating in these already endemic areas. Techniques employed range from environmental sanitation, chemical control, physical control, to educational campaigns. Additionally, given the seriousness of the situation, novel approaches are being considered, such as genetic modification or radiation of the A. aegypti mosquitos.

Environmental Sanitation

The main mode of prevention for these diseases is to limit mosquito contact through vector control [6]. This is primarily done by eliminating habitats that favor the procreation and proliferation of the mosquito [7]. It is important to note that the exception to this is the Zika virus where it has been discovered that sexual (person-to-person) transmission may play a greater role than previously thought [8].  A. aegypti is a “container breeder” and will breed wherever water accumulates [10], even very small amounts, therefore elimination of open sources of stagnant water is the main preventative measure used. Health departments in affected municipalities often form sanitation brigades that go out into the community and visit homes to eliminate or modify sources of stagnant water such as potted plants, toilets, and water leaks. Solid waste such as old tires, open water bottles, and discarded containers are also a hazard because they have the potential to accumulate water and must be eliminated. Water storage containers in homes are fitted with tight lids or mesh screens by the brigades to prevent mosquitos from laying eggs [7, 9, 10,].

Chemical Control

The life cycle stage of the A. aegypti mosquito determines the type of chemical control measure that can be used.  Larvicides, such as Temefos, are used to kill the mosquito in its immature, larval, stages in water containers that cannot be eliminated [6]. During emergency situations, like those that many communities in Latin America are currently experiencing, targeted outdoor residual space spraying is employed. In communities where homes are not adequately screened or air-conditioned, residual indoor spraying is recommended with ultra low volume doses of adulticides, such as deltamethrin and bifenthrin [11]. Finally, in extreme outbreak situations, widespread outdoor space spraying of pesticides is used. This is used as a last-resort measure with rapidly effective treatment in order to reach wide areas. To do the widespread spraying, ultra low volume dose machines are mounted onto trucks and/or aircrafts and the pesticides are dispersed in an aerosol of ultrafine droplets [6, 11]. However, in order for this technique to be effective, the pesticide must come into direct contact with the mosquitoes.

Physical Control

Physical control measures for the A. aegypti mosquito include both physical methods to catch the mosquitos, as well as physical barrier methods. A physical control method is placing oviposition, egg-laying medium on sticky traps in homes to lure female mosquitos and trap them. Some barrier methods include installing screens on windows in the home, wearing protective clothing, like long sleeve shirts and pants, and installing bed nets. Bed nets can be treated with insecticide such as Permethryn to prevent mosquitos from making contact and to kill them at the same time.

Educational Campaigns

Educational campaigns are used concurrently with the environmental sanitation chemical control, and physical control methods in order to inform members of the community of ways to safely protect themselves and rid their communities of the A. aegypti mosquito. In these campaigns, city health departments, in conjunction with sanitation brigades, go out into the community to teach residents and students about the A. aegypti life cycle, how the mosquito reproduces, and ways to eliminate breeding habitats [12]. Some locations such as Rosario, Argentina have dedicated “days of sanitation” or “overhaul weekends” like the one that that Dominican Republic conducted at the end of June 2016. During these sanitation days, everyone works together to eliminate vector-breeding sites in the community and is involved in education campaigns at the same time [13, 14]. The aim of these campaigns is to assist and teach the communities how to eliminate the vector so that they can know the importance of sanitation in disease control, and continue the efforts on their own.

Novel Approaches

There are several novel approaches being discussed as an effort to fight the A. aegypti mosquito. An approach that has been come up a lot recently is the genetic modification (GM) of the male A. aegypti mosquito. The GM male mosquito carries a dominant lethal gene, which is then passed down to its offspring upon mating. The gene causes the mosquito larvae from maturing and thus breaking the mosquito’s life cycle [15, 16]. This approach was successfully tested in the Cayman Islands in 2010 [15] and in June of 2016 was reintroduced in order to prevent Zika and dengue outbreaks [17]. In 2012, Brazil established a farm for GM A. aegypti mosquitos (18) as an effort to reduce dengue outbreaks, and is using this approach in certain areas to fight the current Zika outbreak [19]. According to the United States Food and Drug Authority (FDA) the use of genetically modified mosquitos is safe [20] and Key West, Florida may soon be the first location in the US to test these GM mosquitos [20]. Sterilization through radiation of the male A. aegypti mosquito is another novel approach that has been utilized [15, 21], however it has been shown to not be as effective as the GM mosquitos [22]. Similar to the GM approach, radiation sterilizes male mosquitos so that when they mate, none of the eggs laid would be viable.

It is important to note that no one method by itself is completely effective. Vector control is most effective through a combination of all of these methods [7].

[1] http://espanol.cri.cn/2786/2016/06/23/1s386644.htm

[2] http://larepublica.pe/impresa/sociedad/778842-se-han-reportado-22-mil-casos-de-dengue-este-ano

[3] http://www.diariouno.com.ar/para-reducir-el-dengue-insisten-el-trabajo-la-temporada-invernal-20160619-n967250

[4] http://www.elpais.com.co/elpais/cali/noticias/esperamos-300-casos-microcefalia-asociados-zika-este-ano-ins

[5] http://www.unionjalisco.mx/articulo/2016/06/17/salud/guadalajara/jalisco-es-septimo-en-casos-de-dengue

[6] http://www.cdc.gov/chikungunya/resources/vector-control.html

[7] http://www.who.int/denguecontrol/control_strategies/control_strategy_vector/en/

[8] http://www.cdc.gov/zika/transmission/sexual-transmission.html

[9] http://www.who.int/denguecontrol/control_strategies/environmental_management/en/

[10] http://www.who.int/emergencies/zika-virus/articles/mosquito-control/en/

[11] http://www.cdc.gov/zika/public-health-partners/vector-control-us.html

[12] https://www.diariodemorelos.com/noticias/ense%C3%B1an-en-escuelas-contra-brotes-de-dengue-zika-y-chikungunya

[13] http://www.listindiario.com/puntos-de-vista/2016/06/30/425071/las-necesarias-jornadas-contra-el-zika

[14] http://www.lacapital.com.ar/un-dia-darle-pelea-al-dengue-todo-rosario-n965372

[15] https://journosdiary.com/2016/02/05/novel-approaches-to-fight-aedes-aegypti-mosquito/

[16] http://www.theatlantic.com/technology/archive/2016/04/genetically-modified-mosquitoes-zika/479793/

[17] https://actualidad.rt.com/actualidad/212778-mosquitos-mutantes-islas-caiman-combatir-zika

[18] http://www.healthmap.org/site/diseasedaily/article/brazil-rolls-out-gm-m...

[19] http://www.cbsnews.com/news/brazilian-piracicaba-town-using-genetically-modified-mosquitoes-to-fight-zika/

[20] http://www.nbcnews.com/storyline/zika-virus-outbreak/fda-says-test-genetically-modified-mosquitoes-safe-n536861

[21] http://www.breitbart.com/national-security/2016/02/24/brazil-to-sterilize-zika-mosquitoes-with-radiation/

[22] http://www.nature.com/nature/journal/v244/n5415/abs/244368a0.html

On 25th July 2016, Colombia was the first country in Latin America to declare the end of their Zika outbreak. This comes 10 months after the first case of Zika was detected in the country [1].  Since then, there have been a total of 99,721 cases in Colombia, along with 21 confirmed Zika-linked microcephaly births [2]. However, more cases of Zika-linked microcephaly are expected in the coming months, when pregnant women infected at the peak of the epidemic will give birth [6, 7]. At the peak of the outbreak in February, more than 6,000 cases were reported over the course of a single week [7]; that number has now fallen to less than 600 reported cases per week.

The end of the outbreak in Colombia comes much sooner than predicted by British researchers, which indicated that the outbreak would last in Latin America for an additional two to three years, until enough people gained immunity and the virus burned out [3, 4].  Once infected with the Zika virus, it is believed that people acquire immunity; however, it usually takes several years for enough of the population to acquire immunity for a virus like Zika to die out [3,7]. Some researchers are skeptical about this being the true end of the outbreak; one researcher at the University of Minnesota claims that there is no evidence to support the declaration by the Colombian government [7]. Others believe that this may just be a seasonal decline [7] – as the rainy season approaches its end, there is less stagnant water available for the Aedes agypti mosquito to use as breeding grounds.

Despite the announcement of the end of the epidemic, Colombian authorities still advise that residents continue partaking in preventative measures [5]. Zika is now considered endemic to the country, meaning that the virus will always circulate in Colombia to some degree [7]. 

After Brazil, Colombia has reported the most Zika infections in Latin America [7].

[1] http://www.eluniversal.com.mx/articulo/mundo/2016/07/25/colombia-declara...

[2] https://noticias.terra.com.co/colombia/colombia-da-por-cerrada-epidemia-de-zika,c7088388c83f37402b4cbe5804046768s0hqmn9n.html

[3] http://science.sciencemag.org/content/early/2016/07/13/science.aag0219

[4] http://www.reuters.com/article/us-health-zika-immunity-idUSKCN0ZU29N

[5] http://www.bbc.com/mundo/noticias-america-latina-36889211

[6] http://www.foxnews.com/health/2016/07/25/colombia-declares-end-to-zika-epidemic-inside-country.html

[7] https://www.statnews.com/2016/07/25/colombia-zika-virus-epidemic/

On February 2016, in a district of Piracicaba, Brazil, genetically modified (GM) mosquitoes were released in an effort to reduce diseases transmitted by the Aedes aegypti mosquito. Now, five months later, it has been announced that the incidence of dengue in this district has fallen by 91%. This reduction can be compared to the 52% decrease in incidence in the rest of Piracicaba, where the only vector control measure employed was the elimination of standing water sources [1-3].

The GM male mosquitoes produced by the company Oxitec carry a dominant lethal gene that prevents the mosquitoes from producing viable offspring, thus breaking the mosquito’s life cycle. GM male A. aegypti mosquitoes must first be released in an affected area, here they will reproduce with wild female A. aegypti mosquitoes and pass their copy of the lethal gene to their offspring. These offspring do not survive past the larval stage and will therefore not have an opportunity to become disease vectors or to proliferate the species [2, 4].

If employed, this method of vector control would have a significant positive impact on the environment by eliminating the need to use pesticides. Pesticides have the potential to harm and bio-accumulate in wildlife and to persist in the environment. However, some scientists argue that the GM mosquitoes’ environmental safety has yet to be proven [2].

The positive results from this small trial in Piraciaba (population of approximately 5,000 people) are a step in the right direction in Brazil’s fight to control their Zika outbreak, which is also transmitted by A. aegypti. However, the GM mosquitoes are still in the trial stage in Brazil. Before a widespread release of the mosquitoes can occur, which have been classified as a ‘novel medical technology’ by the Brazilian health regulatory agency (Anvisa), Oxitec must prove that this novel technology is safe and that it can reduce the transmission of vectorborne illness [2]. Before being tested in Piracicaba, successful trials of the GM mosquitoes had already taken place in Juazeiro, Bahia state, Brazil; Malaysia; and the Cayman Islands [5]. Despite Oxitec having shown that the GM mosquitoes are safe and effective at reducing A. aegypti populations, there has not been evidence published stating that through these measures, the rates of disease are effectively reduced [2].   

Results of the trial in Piracicaba come at the heels of a study published by British researchers stating that the Zika outbreak in Latin America could last for at least three more years [6, 7]. The Zika outbreak has already led to 1,709 babies born with Zika-linked microcephaly [8]. If the outbreak persists for three more years, it has the potential to cause an even more significant long-term public health impact.

[1] http://www.nature.com/news/the-week-in-science-15-21-july-2016-1.20278

[2] http://www.nature.com/news/why-transgenic-insects-are-still-not-ready-for-prime-time-1.19804

[3] https://www.newscientist.com/article/2097653-first-evidence-that-gm-mosquitoes-reduce-disease/

[4] http://www.eluniversal.com.mx/articulo/nacion/politica/2016/07/21/combate-al-dengue-arroja-resultados-positivos-informe

[5] http://www.nature.com/news/brazil-tests-gm-mosquitoes-to-fight-dengue-1.10426

[6] http://science.sciencemag.org/content/early/2016/07/13/science.aag0219

[7] http://www.reuters.com/article/us-health-zika-immunity-idUSKCN0ZU29N

[8] http://www.business-standard.com/article/news-ians/brazil-confirms-1-709...