Strengthening preparedness for (re-) emerging arboviruses in Europe
SIGFRID, L, et al.
SIGFRID, L, et al . Strengthening preparedness for (re-) emerging arboviruses in Europe.
Clinical Microbiology and Infection , 2018, vol. 24, no. 3, p. 219-220
DOI : 10.1016/j.cmi.2018.02.001 PMID : 29496185
Disclaimer: layout of this document may differ from the published version.
1 / 1
Strengthening preparedness for (re-) emerging arboviruses in Europe
This theme issue draws attention to arboviral diseases: arbovi- ruses (arthropod-borne viruses) are predominantly transmitted between vertebrate hosts by arthropod vectors, such as ticks, mosquitoes and sand-ﬂies. Although arboviral infections are not the most common diagnosis in clinical and clinical microbiology practices in most of Europe, events of the past years raise the ques- tion: is Europe prepared to deal with expansions or outbreaks of ar- boviruses? Globally, the burden of arboviral disease is huge, with more than 100 million cases, 100 000s of deaths, and an unknown number of chronic complications. An important observation is that the geographic distribution of arboviral diseases has under- gone quite dramatic changes in past decades, with recent global and regional expansion of e.g. West Nile virus (WNV), chikungunya virus (CHIKV), dengue virus (DENV) and Zika virus (ZIKV), with associated travel-imported cases in Europe. Zika virus, a previously known but not well studied arbovirus, gained attention in 2015 when the Brazilian Ministry of Health alerted the world to an in- crease in congenital anomalies and neurological disease, thought to be linked to a large ZIKV outbreak across naïve areas in South and Central America. Since then a link between ZIKV and severe neurological complications has been established, and sexual and transfusion related transmission has been documented[2e4]. The ZIKV outbreak resulted in a large number of travel-imported cases globally and highlighted the need to strengthen preparedness to (re-) emerging epidemics globally, to enable earlier detection of outbreaks and implementation of rapid clinical research responses.
How do these global epidemics affect Europe? Europe already hosts a range of endemic arboviruses of clinical signiﬁcance, with tick-borne encephalitis virus and Crimean-Congo haemorrhagic fe- ver virus (CCHFV) arguably of most relevance and Toscana virus emerging as a leading cause of aseptic meningitis in regions of southern Europe[5e7]. In addition, concomitant with the global expansion of WNV, endemic circulation of WNV is now established in parts of Europe, and CHIKV has sparked recent outbreaks in Italy and France[6,8]. These examples demonstrate the difﬁculty in pre- dicting the fate of arbovirus incursions: whereas in the Americas WNV expanded over the course of a few years, the human arbovirus disease outbreaks in Europe have so far remained relatively local- ized. While it is tempting to explain this by climate conditions, this does not explain the widespread veterinary arboviral disease outbreaks caused by blue tongue virus and Schmallenberg virus that has occurred in Northern Europe[9,10].
An important question therefore is how to be prepared for arboviral diseases in the European context. The increasing reports of non-vector transmission, such as sexual transmission of ZIKV [2,4]and the risk of blood transfusion transmission for many arbo- viruses[6,11]emphasize the need for early pathogen detection to
prevent the risk of onward transmission. While non-vector trans- mission from body ﬂuids has been reported for several arbovi- ruses, with 27 different viruses detected in human semen[12,13]
and the risk of nosocomial transmission of CCHFV well docu- mented[14e16], there is still limited evidence on the risk of trans- mission from different body ﬂuids for most arboviruses. The recent CHIKV outbreak in Italy prompted ECDC to issue pre- cautionary guidance to member states on screening of blood prod- ucts and blood donation deferrals , despite limited evidence, highlighting the need for further research on effective and appro- priate control policies.
Travel medicine aside, in regions with known endemic arboviral presence, or at risk for incursions, front line staff, including clini- cians and virologists, play a key role in the early identiﬁcation of human cases and outbreaks. The identiﬁcation of arboviruses is however complex. Arbovirus infections can present with a range of non-speciﬁc, overlapping syndromes. This is further compli- cated by complex diagnostics, with serological cross-reactivity be- tween related arboviruses. Moreover, the documented high proportion of mild or asymptomatic cases, can also contribute to delays in identiﬁcation of outbreaks. Using a syndromic approach together with detailed patient history and vaccination status, coupled with an understanding of seasonality and current epidemi- ology can help guide differential diagnosis.
This theme issue aims to raise awareness of the changing epide- miology and increasing threat of arboviruses in Europe, with the objective of strengthening preparedness and response to the detec- tion of cases and outbreaks. The issue comprises three reviews related to the ESCMID Postgraduate education course “Preparing for (Re-) Emerging Arbovirus Infections in Europe” which was held in 2016 and 2017 and is planned again for 2018. Theﬁrst re- view by Sigfridet al,presents an update on epidemiology, risk fac- tors, syndromic presentation and treatment of arboviruses of clinical signiﬁcance to Europe. This paper also presents models predicting further expansion of Ae. aegypti, Ae.albopictus and CCHFV in Europe. The second review by Reuskenet al,is focused on European laboratory preparedness and response capacity.
This review illustrates the needs for laboratory preparedness espe- cially to endemic and (re)-emerging arboviruses. It identiﬁes the components and barriers of such preparedness and discusses the laboratory preparedness in the broader context of the current and widening landscape of international research, clinical and labora- tory preparedness networks. The third review by Eckerle et al, aims to raise awareness and strengthen preparedness among clini- cians by presenting a series of case-reports of travel-imported arbo- viruses, with differential diagnostics, presenting at secondary care across three European countries.
Contents lists available atScienceDirect
Clinical Microbiology and Infection
j o u r n a l h o m e p a g e :w w w . c l i n i c a l m i c r o b i o l o g y a n d i n f e c t i o n . c o m Clinical Microbiology and Infection 24 (2018) 219e220
1198-743X/©2018 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Strengthening clinical preparedness is the mission of the EU funded Platform for European Preparedness Against (Re-) emerging Epidemics (PREPARE). PREPARE was set up in 2014, with a mission to strengthen clinical preparedness and facilitate early identiﬁca- tion and rapid clinical research responses to (re-) emerging infec- tious diseases with epidemic potential across Europe. To achieve this, PREPARE partners are strengthening networks of primary and secondary care sites, identifying regulatory barriers to rapid clinical responses, and developing syndromic research tools and frameworks for rapid clinical research responses. For diagnostic guidance, PREPARE clinical researchers collaborate with laboratory experts involved in laboratory preparedness activities, which for ar- boviruses is the EVD-LabNet network. The protocols and tools are tested through pan-European studies designed to enrol patients presenting with syndromes of severe infectious diseases with epidemic potential, including those caused by arboviruses. PRE- PARE is a model for a network of coordinated, regional prepared- ness hubs to facilitate harmonised, rapid research responses to infectious disease outbreaks globally.
The authors declare no conﬂicts of interest.
This work forms part of the PREPARE (Platform for European Preparedness against (re-)emerging epidemics funded by the Euro- pean Commission under grant number 602525.
 Gould EA, Solomon T. Pathogenicﬂaviviruses. The Lancet 2008;371:500e9.
 Baud D, Gubler DJ, Schaub B, Lanteri MC, Musso D. An update on Zika virus infection. Lancet 2017;390:2099e109.
 Musso D, Baud D, Gubler DJ. Zika virus: what do we know? Clin Microbiol Infect 2016;22:494e6.
 Moreira J, Peixoto TM, Siqueira AM, Lamas CC. Sexually acquired Zika virus: a systematic review. Clin Microbiol Infect 2017;23:296e305.
 Papa A. Emerging arboviral human diseases in Southern Europe. J Med Virol 2017;89:1315e22.
 Cleton N, Koopmans M, Reimering J, Godeke G, Reusken C. Comeﬂy with me Review of clinically important arboviruses for global travelers. J Clin Virol 2012.
 Charrel RN, Gallian P, Navarro-Mari JM, Nicoletti L, Papa A, Sanchez-Seco MP, et al. Emergence of Toscana virus in Europe. Emerging Infect Dis 2005;11:
 ECDC. Clusters of autochthonous chikungunya cases in Italy - rapid risk assessment. 2017.
 Wernike K, Conraths F, Zanella G, Granzow H, Gache K, Schirrmeier H, et al.
Schmallenberg virusdTwo years of experiences. Prev Vet Med 2014;116:
 Jacquot M, Nomikou K, Palmarini M, Mertens P, Biek R. Bluetongue virus spread in Europe is a consequence of climatic, landscape and vertebrate host factors as revealed by phylogeographic inference. Proc Biol Sci 1864;2017:284.
 Musso D, Gould E, Lanteri MC. Documentation of transfusion-transmitted arbovirus infections in endemic areas. Transfusion 2016;56:3143e4.
 Salam AP, Horby PW. The breadth of viruses in human semen. Emerg Infect Dis 2017;23:1922e4.
 Musso D, Richard V, Teissier A, Stone M, Lanteri MC, Latoni G, et al. Detection of Zika virus RNA in semen of asymptomatic blood donors. Clin Microbiol Infect 2017;23:1001.e1ee3.
 Aradaib IE, Erickson BR, Mustafa ME, Khristova ML, Saeed NS, Elageb RM, et al.
Nosocomial outbreak of Crimean-Congo hemorrhagic fever, Sudan. Emerging Infect Dis J 2010;16:837.
 Gürbüz Y, Sencan I, Oztürk B, Tütüncü E. A case of nosocomial transmission of CrimeaneCongo hemorrhagic fever from patient to patient. Int J Infect Dis 2009;13:e105e7.
 Elata AT, Karsany MS, Elageb RM, Hussain MA, Eltom KH, Elbashir MI, et al. A nosocomial transmission of crimean-Congo hemorrhagic fever to an attending physician in north kordufan, Sudan. Virol J 2011;8:303.
 Cleton NB, Reusken CBEM, Wagenaar JFP, van der Vaart EE, Reimerink J, van der Eijk AA, et al. Syndromic approach to arboviral diagnostics for global travelers as a basis for infectious disease surveillance. PLOS Neglected Trop Dis 2015;9, e0004073.
 Sigfrid L, Reusken C, Eckerle I, Nussenblatt V, Lipworth S, Messina J, et al. Pre- paring clinicians for (re-)emerging arbovirus infectious diseases in Europe.
Clin Microbiol Infect 2018;24:229e39.
 Reusken CB, Ieven M, Sigfrid L, Eckerle I, Koopmans M. Laboratory prepared- ness and response with a focus on arboviruses in Europe. Clin Microbiol Infect 2018;24:221e8.
 Eckerle I, Briciu VT, Erg€onülO, Lups¸e M, Papa A, Radulescu A. Emerging€ souvenirsdclinical presentation of the returning traveller with imported arbovirus infections in Europe. Clin Microbiol Infect 2018;24:240e5.
L. Sigfrid* Centre for Tropical Medicine and Global Health, Nufﬁeld Dept. of Medicine, University of Oxford, Oxford, UK I. Eckerley University of Bonn Medical Centre, Institute of Virology, Bonn, Germany A. Papa Aristotle University of Thessaloniki, Dept. of Microbiology, Thessaloniki, Greece P. Horby Centre for Tropical Medicine and Global Health, Nufﬁeld Dept. of Medicine, University of Oxford, Oxford, UK M. Koopmans, C. Reusken Department of Viroscience, WHO Collaborating Center for Arboviruses and Viral Haemorrhagic Fever Reference and Research, Erasmus University Medical Centre, Rotterdam, The Netherlands
E-mail address:firstname.lastname@example.org(L. Sigfrid).
Editor: L. Leibovici
yPresently at: Geneva Centre for Emerging Viral Diseases, Division of Infectious Diseases, University hospital of Geneva, Switzerland.
Editorial / Clinical Microbiology and Infection 24 (2018) 219e220 220