Volume 5, Number 4—August 1999
West Nile Fever in Czechland
To the Editor: After heavy rains in July 1997, extensive floods occurred along the Morava River, Czech Republic. Populations of Aedes mosquitoes increased rapidly in the flooded areas, prompting surveillance for mosquito-borne virus infections in the Breclav area, South Moravia. We collected 11,334 female mosquitoes (9,100 Aedes vexans, 917 Ae. cinereus, 11 Ae. cantans, 1,074 Ae. sticticus, and 232 Culex p. pipiens) from July through September 1997 and tested them for virus in 117 monospecific pools by intracranial inoculation of suckling mice. Seven virus isolates were obtained and identified by complement-fixation and neutralization tests. Six isolates (five from Ae. vexans, one from Ae. cinereus) were identified as the bunyavirus Tahyna, California serogroup, and one (strain 97-103 from 57 C. p. pipiens collected at Lanzhot, 48o40'N, 16o56'E, on September 17) was identified as the flavivirus West Nile (1). A crossed comparison of 97-103 and topotype Eg-101 (2) West Nile virus strains and their antisera (prepared in mice by three intraperitoneal doses at weekly intervals) by plaque reduction neutralization (PRN) on XTC-2 cells (3,4) showed their antigenic relationships: reciprocal titers of homologous/heterologous sera were 512/512 in Eg-101 and 512/64 in 97-103. Strain 97-103 has lower virulence than Eg-101 in that it does not kill adult ICR mice and may represent a subtype of West Nile virus.
Blood samples were obtained from 619 persons seeking treatment at hospital and outpatient clinics in the Breclav area from June 23 through September 29, 1997. Sera were inactivated at 56°C for 30 minutes, diluted 1:8, and assayed by PRN for antibodies against c. 30 plaque-forming units (PFU) per well of West Nile virus strains Eg-101 and 97-103. All sera causing 90% reduction of PFU at 1:8 dilution were titrated, and the highest serum dilution showing 50% PFU reduction was regarded as the titer. Antibodies neutralizing West Nile virus were detected in 13 (2.1%) persons: 2.8% of 179 male and 1.8% of 440 female. Persons with detectable West Nile virus antibody were questioned about their health history during the previous 5 years, and their medical records were reviewed; none recalled having had tickborne encephalitis (Central-European encephalitis [CEE] virus is the only other flavivirus present in Czechland) or having been vaccinated against CEE or yellow fever virus. Titers of PRN antibodies to CEEV were all below 16. Two of the seropositive persons had traveled abroad during the last 5 years: one to Croatia in 1996, and one to South Australia during 1951 to 1994.
Paired serum samples were obtained from 72 of the 619 persons examined. A significant increase (>4 times) in antibody titer against West Nile virus between the first (acute-phase) and second (convalescent-phase) samples was detected four times: in 2 of 41 young persons (<16 years of age) and in 2 of 31 adults (>16 years of age). Among the four seroconverting persons, only the two children had clinical symptoms compatible with West Nile fever. A 9-year-old boy had fever (39oC) for 4 days, sore throat, headache, muscle ache, pronounced fatigue, and nausea lasting approximately 6 days, with recovery after 13 days. Neutralizing antibodies to West Nile virus, Eg-101 and 97-103, were 64 and 32 on July 22 and 512 and 256 on August 4, respectively. A 9-year-old girl had fever (38°C-39°C) for 3 days, sore throat, headache, muscle ache, pronounced fatigue, nausea, vomiting, maculopapular rash (including flushed face), and slightly enlarged inguinal lymph nodes. The illness lasted approximately 7 days, with complete recovery after 17 days. Neutralizing antibodies to West Nile virus, Eg-101 and 97-103, were 64 and 32 on August 6 and 256 and 128 on August 20, respectively. Of the remaining nine seropositive persons lacking paired serum samples, one had severe headache, muscle ache, prolonged fatigue, nausea, pain on eye movement, maculopapular rash, and insomnia in summer of 1997. Two other persons had had "summer fever" (sore throat and lymphadenitis; headache with pain on eye movement) in 1997. The other persons who seroconverted did not report any substantial illness. In total, clinical symptoms in five persons are compatible with West Nile fever.
These are the first reported human cases of West Nile fever in Central Europe (5); an extensive outbreak occurred in Romania in 1996, with approximately 500 patients hospitalized and a 4% to 8% fatality rate (6,7). West Nile virus should be viewed as a potential agent of local sporadic cases, clusters, or outbreaks, even in temperate Europe. Environmental factors (including human activities) that enhance vector population densities (heavy rains followed by floods, irrigation, higher than usual temperatures due to global warming) might produce an increased incidence of West Nile fever and other new or reemerging mosquito-borne diseases. Surveillance for West Nile fever should monitor population density and infection rate of principal vectors, antibodies in vertebrates and exposed human groups, and routine diagnosis of human infections.
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