Italy battles imported viral chikungunya epidemic

[Gert van der Hoek]

Archive Number 20070901.2877
Published Date 01-SEP-2007
Subject PRO/EDR> Chikungunya - Italy (Emilia Romagna): susp.



CHIKUNUNYA - ITALY (EMILIA ROMAGNA): SUSPECTED
**********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Fri 31 Aug 2007
From: Walter Oscar Pavan wo.pavan@ausl.ra.it


In the little town of Castiglione di Cervia (province of Ravenna,
Italy), since mid July 2007, several people have been attended at the
hospital and health centres with high fever and arthralgia, joint and
muscular pain, severe headaches, body aches and, in some cases, a
rash was also noted.

Since the beginning of August 2007, an increasing number of febrile
syndromes associated with arthralgia have been recorded in the
general population of the area. Initially, only dozens of residents
were infected; now that number has jumped to about 100-150. Many of
the sufferers are already better, but the number of new infections is
still on the rise.

The patients had been suspected of being infected with chikungunya
virus based on the clinical presentation. Health authorities had
fumigated the village to kill the _Aedes albopictus_ mosquitoes that
infest the area, had taken blood samples from patients, and sent the
samples to the laboratory of the Istituto Superiore di Sanita --
E0-ISS (the leading technical and scientific public body of the
Italian National Health Service). However, we have not yet received
the results of the lab tests.

Castiglione is few km south southeast of Ravenna, in Emilia Romagna
Region, Italy.

--
Dr. Walter Oscar Pavan, M.D.
Emilia Romagna Region - Department of Health
Public Health Service
Lyme Borreliosis Regional Referral Centre
Via Zaccagnini, 22
48018 Faenza - Italy
wo.pavan@ausl.ra.it

[There have been numerous cases of chikungunya virus infection
imported into Europe within the past 2 years, originating in the
massive Indian Ocean outbreak. Until this current suspected outbreak
in Italy, none of the importations has resulted in subsequent
transmission of the virus. It is not surprising that a chikungunya
virus outbreak has likely occurred in a European area where a
competent mosquito vector, _Aedes albopictus_, is abundant. This
should serve as a warning for other localities where this mosquito is present.

A map of the Emilia Romagna region and its location in Italy can be accessed at
http://www.knowital.com/italy/maps/emiliaromagnamap.html. - Mod.TY]

[By the clinical description, this could also be dengue, which is
also vectored by _Aedes albopictus_. Dengue is imported all over
Europe & to the USA by travelers -- see ProMED 2006 & 2003 archives
below -- just waiting for its chance to get into a competent vector
in the northern summer season. - Mod.JW]

http://www.promedmail.org/pls/prome..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,39093

 

[tropical]

Re: Italy: chikungunya suspected

Re: Italy: chikungunya suspected

chikungunya_Italy_report06_aug07.pdf

 

[Gert van der Hoek]

Re: Italy: chikungunya confirmed

Re: Italy: chikungunya confirmed

Archive Number 20070902.2889
Published Date 02-SEP-2007
Subject PRO/EDR> Chikungunya - Italy (Emilia Romagna) (02): conf.



CHIKUNGUNYA - ITALY (EMILIA ROMAGNA): CONFIRMED
**********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Sat, 01 Sep 2007 21:48:14 +0200
From: Giuseppe Michieli <gimi69@libero.it> [edited]
Source: Ministry of Health, Italy [in Italian]
http://www.ministerosalute.it/imgs/C_17_comunicati_1365_testo.rtf


[Re ProMED post Chikungunya - Italy (Emilia Romagna): susp. 20070901.2877]

Your latest post concerning a suspected outbreak
of chikungunya fever in Italy (Emilia Romagna)
appears to be confirmed by a note dispatched by
Ministry of Health [see Source above]. A paragraph in this document reads:

''I risultati degli esami di laboratorio eseguiti
dal Dipartimento di malattie infettive dell?Iss
su campioni biologici delle persone colpite,
indicano invece come causa del focolaio epidemico il virus Chikungunya.''

(Laboratory test analysis on patients' samples
indicate causative agent of this illness is
chikungunya virus. - My translation.)

Whether an infected traveler is to blame for the
outbreak or a persistent presence of the virus in
the mosquito population remains to be
established. [See comment below. - Mod. JW]

--
Communicated by:
Giuseppe Michieli
Via Vittorio Saetta 26A - 35132 Padova
Italy
Website: <http://hygimia69.blogspot.com>
NON-HEALTH CARE WORKER
Non-health care worker

[ProMED is indebted to Giuseppe Michieli for this source & its translation.

Note that "chikungunya" takes a lower-case
initial inside a sentence, just like "dengue",
because the word describes a symptom (joint pain in both cases).

The reference to persistence in mosquitoes refers
to the importation of a number of cases last year
(2006), in travelers returning from epidemic
areas in the Indian Ocean islands & India, which
could have infected local mosquitoes, although no
local epidemic was recognized at the
time.

ProMED archive Chikungunya - Indian Ocean
update (09): islands, India 20060320.0864, March
2006, mentions the importations into Italy &
other European countries. A just published paper
kindly forwarded by ProMED Moderator Emeritus Charlie Calisher is:

Beltrame A, Angheben A, Bisoffi Z, Monteiro G,
Marocco S, Calleri G, et al. Imported chikungunya
infection, Italy [letter]. Emerg Infect Dis
[serial on the Internet]. 2007 Aug. Available
from http://www.cdc.gov/EID/content/13/8/1264.htm

Since dengue is also spread by the same vector
species of mosquito as chikungunya, clearly Italy
is now wide open for imported cases of dengue to
start an epidemic. It is hoped that the relevant
authorities there have taken note of the risk. - Mod.JW]

http://www.promedmail.org/pls/askus..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,39105

 

[tropical]

Re: Italy: chikungunya confirmed

Re: Italy: chikungunya confirmed

Archive Number 20070902.2889
Published Date 02-SEP-2007
Subject PRO/EDR> Chikungunya - Italy (Emilia Romagna) (02): conf.
CHIKUNGUNYA - ITALY (EMILIA ROMAGNA): CONFIRMED
**********************************************
Date: Sat, 01 Sep 2007 21:48:14 +0200
From: Giuseppe Michieli <GIMI69@LIBERO.IT>[edited]
Source: Ministry of Health, Italy [in Italian]
http://www.ministerosalute.it/imgs/C_17_comunicati_1365_testo.rtf
...
Beltrame A, Angheben A, Bisoffi Z, Monteiro G,
Marocco S, Calleri G, et al. Imported chikungunya
infection, Italy [letter]. Emerg Infect Dis
[serial on the Internet]. 2007 Aug. Available
from http://www.cdc.gov/EID/content/13/8/1264.htm

In fact this is the same document (text) from the previous pdf post:
chikungunya_Italia_report06_aug07.pdf
Emerging Infectious Diseases - www.cdc.gov/eid, Vol. 13, No. 8, August 2007, pages 1264-1266.

 

[Snowy Owl]

Re: Italy battles imported viral epidemic

Re: Italy battles imported viral epidemic

September 07, 2007 Italy battles imported viral epidemic


By Phil Stewart


ROME (Reuters)


A small region in northern Italy is battling what may be Europe's first epidemic of the crippling, mosquito-borne Chikungunya virus, a senior official at the Italian National Institute of Health (ISS) told Reuters.


About 160 cases have been confirmed in Italy and another 30 victims of the non-fatal but painful disease are suspected, said Antonio Cassone, the ISS's director of the department of Infectious, Parasitic and Immune-Mediated Diseases.


Symptoms include high fever, joint and muscular pain, severe headaches, nausea, vomiting, body aches and a rash similar to that seen in dengue fever patients. Still, it is not believed to be fatal in itself.


Cassone said Italy and other European states had previously detected cases of Chikungunya inside their borders, but only among people who had been infected abroad, particularly in Africa and India.

"This is the first time that in Europe we have an epidemic. That means local transmission, not only importation of a case," said Cassone.


"We had in the past several important cases, but the diseases stopped with the (carrier). The person coming from the affected area in India or Africa just had the fever, but there was no local transmission."


INDIAN TOURIST
Cassone said researchers identified a man from southern India as the possible source of the virus, which started spreading in July in the small northern Italian hamlet of Castiglione, in Ravenna province.


Mosquitoes bit the man while he was staying with relatives in Castiglione. The bugs then spread the virus to the four other people in the house, infecting all of them.


Cassone said that one 86-year-old man died after contracting the virus, but that the patient had already been hospitalized and was very ill.


The U.S. Centers for Disease Control and Prevention (CDC) says no deaths from Chikungunya have been documented in scientific literature.


Regional authorities have said efforts to contain the virus had so far been largely successful, adding the rate of infection had dropped sharply since mid-August.


Cassone said there were no travel restrictions being placed on residents from the affected areas. But they were advised to be vigilant to possible symptoms of the virus and take measures to ward off mosquitoes, like using repellent.


The World Health Organization is in close contact with Italian authorities on the issue, a press officer said.

http://www.sciam.com/article.cfm?alias=italy-battles-imported-vi&chanId=sa003&modsrc=reuters

 

[tropical]

Re: Italy battles imported viral epidemic

Re: Italy battles imported viral epidemic

September 07, 2007 Italy battles imported viral epidemic

I think is important translate few parts of a previous Snowy Owl post:
IN ROMAGNA: confermato tracce del virus Chikungunya in quattro casi
Snowy Owl
...

Correlation contents (Contenuti correlati )

Tiger mosquito virus, blood donations suspended
Virus da zanzara tigre, sospese le donazioni di sangue

Misterious infection: two suspected cases in Bologna
Contagio misterioso: due casi sospetti a Bologna

Tiger mosquito nightmare, 140 thousend houses to disinfect
Incubo zanzara tigre, 140 mila case da disinfestare


<!-- / message --><!-- sig -->

 

[Gert van der Hoek]

Re: Italy battles imported viral epidemic

Re: Italy battles imported viral epidemic

Machinetranslation

Virus Chikungunya, nearly 200 cases

Confirmed 166 infections

There are 197 cases suspected of infection from virus Chikungunya signals to you up to now, of which already 166 confirmed. It reveals the Higher Institute of Health (Iss), than to the emergency released in province of Ravenna and Cesena has dedicated a focus on its situated Internet.

“The epidemic curve - Gianni Rezza explains, director of the unit epidemiologia of the department parasitic and immunomediate infectious diseases - has caught up its apex to half of the August month, and appears in reduction.

But the insorgence of other small focolai in contiguous areas to that initially hit, or of sporadic cases in persons who have visited the area slices, marks it the necessity to hold high the level of allerta”.

In fact, a careful surveillance reveals the investigator of the single Iss “, which that one up to now put into effect can favor the adoption of participations of disinfestazione appropriates to you and timely, like that they have contributed to hold under control the focolaio begins them and to contain eventual new focolai of transmission of the virus”.

The Iss remembers that the Chikungunya is a passed pathology to generally benign, “that we hope of being able to control. The fact remains that phenomena of which as well as it is spoken, like the climatic globalization and changes us, seem for before the time to have battered a blow”, comments Rezza.

Virus the Chikungunya, transmitted from the so-called mosquito tiger (Aedes albopictus) and from other mosquitos of the sort Aedes, is endemic in various tropical Countries and is currently present in epidemic shape in the area of the Indian Ocean.

They have been signals in our Country at least 30 cases to you in persons who have made return from hit areas. They were not but it signals to you focolai native of transmission up to now.

“The identification of the focolaio epidemic of fever from virus Chikungunya in Romagna evidences in exemplary way - Rezza concludes - how much is important to preview the exotic possibility of circulation of virus also in our Country and deciding of diagnostic techniques in a position to identifying them with timeliness”.

While, the Region Emilia Romagna has adopted measures for the trasfusionale emergency. In particular, the Avis of Bologna makes to know that units of blood and plasma will not be used captured from the first August 2007 in the common ones of Ravenna, Cervia, Cesena and Cesenatico.

The candidates will not be admitted to the donation neanche donors who have soggiornato, in the 3 previous weeks the day of the donation, in the aforesaid zones.

http://www.giornaletecnologico.it/scienza/200709/07/46e01c72026f9/

 

[Gert van der Hoek]

Re: Italy battles imported viral epidemic

Re: Italy battles imported viral epidemic

Published online: 6 September 2007;


Tiger mosquitoes bring tropical disease to Europe

Invasive species could cause Chikungunya to become endemic.

Emiliano Feresin



Tiger mosquitoes could bring many diseases to Europe.


The arrival of a tropical mosquito-borne disease in Italy has experts worried that such illnesses may become endemic in Europe.

Local authorities in Bologna, Italy, this week ordered parts of the city to implement mosquito-control measures prevent the spread of the flu-like viral disease, Chikungunya. The disease is carried by the tiger mosquito (Aedes albopictus) and is more usually found in African and Asian countries.

Chikungunya hit two villages, some 80 kilometres east of Bologna, this summer. Nearly 200 people are thought to have been infected and one has died of complications. The number of new cases is now decreasing, but suspected cases have started to appear in the city.

The tiger mosquito is a relative newcomer in Europe, which has spread to Italy, France, Belgium, the Netherlands and the Balkan region over the past decades. It lives in urban areas and feeds mostly on human blood. The bites are painful, but, until now, have usually been harmless.

Experts fear that the recent spate of disease may allow Chikungunya to become endemic in this area ? or, even worse, the more dangerous dengue virus that the tiger mosquito can also carry.

European first

The Italian outbreak started in early July, but was at first mistaken for simple flu. Authorities now think that a tourist returning from India imported the Chikungunya virus to Italy, where it spread among the dense population of tiger mosquitoes.

Chikungunya means 'that which bends up' in Makonde, a local language of Tanzania and Mozambique, describing the joint pain that accompanies the illness's high fever. In 2005, the disease affected hundreds of thousands of people in the Indian Ocean islands and later spread throughout India, where it had not been seen for several decades (see ''Disease outbreaks highlight India's poor mosquito control'').

"Isolated cases of imported Chikungunya disease have occurred in Europe," says Herv? Zeller, virologist at the Institute Pasteur of Lyon, France. "But this is the first time that transmission from local mosquitoes has occurred here".

Uncertain spread

Scientists say they don't yet know enough to say for sure whether the disease will spread from northern Italy to other European countries infested with the tiger mosquitoes. "We don't even know why West Nile disease became endemic in North America but not in Europe, even though the virus and the vector are present on both continents," says Evelyn Depoortere, an epidemiologist at the European Centre for Disease Prevention and Control in Stockholm. "We need a lot more research on the environmental factors that affect how insect-borne viruses spread," Says Zeller.

They point out that although the current outbreak is damping down, thanks to efficient control measures and cooling temperatures, it could re-occur next year. Recent research in tropical areas has shown that infected female tiger mosquitoes transmit the Chikungunya virus to their eggs. Mosquito eggs easily survive mild Mediterranean winters.

Officials at the World Health Organization (WHO) in Geneva, Switzerland, doubt that it will be possible to eradicate the mosquitoes. "They are very persistent," says Michael Nathan, an entomologist at WHO. Italy and France have already spent a lot of money trying ? to little effect, he says. "But since we don't have a vaccine or drugs against the Chikungunya virus, the only option we have is efficient mosquito control."

In Bologna, doctors have been told to take special care in diagnosing flu-like illnesses. "We are fighting to keep Chikungunya out of our territory," says a local government official.

http://www.nature.com/news/2007/070...l;jsessionid=6E5757213FFBE0CB34C7265005CC1FBD

 

[Gert van der Hoek]

Re: Italy battles imported viral epidemic

Re: Italy battles imported viral epidemic

254 Cases of Chikungunya Fever Confirmed in Italy

By Jeanne Marie Kerns

Published Sep 17, 2007

According to the Centers for Disease Control news release, Italian Health has
reported 254 cases of chikungunya fever, which is transmitted through
mosquitoes.

As stated by the World Health Organization, Chikungunya fever is a viral illness
that is characterized by severe joint pain, as well as a fever and a rash that
covers all parts of the body. Fortunately, chikungunya fever is not a life
threatening disease, however symptoms from the disease can require medications
up to a year after infection.

There is no drug treatment at all against
chikungunya fever, bed rest, plenty of fluids and medication such as ibuprofen
or acetaminophen will help when it comes to the aches and pains. Taking aspirin
is not recommended while ill with this virus since aspirin increases the risk
for Reye's Syndrome.

The cases which have been reported by the Italian Health are in the province of
Ravenna, Emilia-Romagna which is in northeast Italy. The two villages where
reports have been more intense are in Castiglione di Ravenna and Castiglione de
Cervia. Tests that have been conducted show that the local mosquitoes are indeed
responsible for transmitting the infection.

Since Italy is full of travelers, the Italian Health authorities are urging all
residents as well as tourists to take the necessary precautions to avoid coming
in contact with mosquitoes. The best way to do this is to follow these
instructions. Try and wear long sleeve shirts, pants, and long dresses to cover
your arms and legs while outside.

Always while outside use insect repellent on any skin that is exposed. If there
is no need to go anywhere during the times mosquitoes like to roam around (early
morning, early evening) then stay inside. Be sure that whenever you are staying
in a hotel that if the windows are open that screens are present when opened. If
possible, keep all windows shut and air conditioning on. Also, be sure that
there are no containers outside that have water in them, if you do, empty them
immediately. Water is a breeding ground for mosquitoes.

Next week a team of health experts led by the European Center for Disease
Prevention and Control will be in Italy next week to go over experiences and
discuss the possible impact of the chikungunya virus in other European
countries.

SOURCE : Chikungunya Fever in Italy
http://wwwn.cdc.gov/travel/contentChikungunyaFeverItaly.aspx

SOURCE: European Center for Disease Prevention and Control
http://www.ecdc.eu.int/


http://www.associatedcontent.com/article/380978/254_cases_of_chikungunya_fever_confirmed.html

 

[Snowy Owl]

Re: Italy battles imported viral epidemic

Re: Italy battles imported viral epidemic

[FONT=ariel,helvetica][SIZE=-1]BMJ, doi:10.1136/bmj.39342.563310.80 (published 18 September 2007)[/SIZE][/FONT]
Editorials

Chikungunya in Italy

Globalisation is to blame, not climate change



<table align="center" border="1" cellpadding="5" hspace="4" vspace="4"><tbody><tr><td align="center" bgcolor="#ffffff">[SIZE=-1]The first 150 words of the full text of this article appear below.[/SIZE]</td></tr></tbody></table>

An epidemic of chikungunya virus has recently occurred in Italy,involving more than 190 cases.¹ The concern is that climatechange will bring mosquito borne tropical diseases to NorthernEurope, but is this outbreak really the result of global warming?Although such an epidemic is new in Europe, it is probably causedby globalisation rather than climate change. Increased amountsof long distance tourism, travel, and trade mean that organismsthat live in and on people or goods have more opportunity tobe transported across continents.


Chikungunya is an epidemic disease with many similarities todengue?it causes fever that lasts four to seven days,sometimes with a rash. It is often accompanied by intense arthralgia.²Most infections cause noticeable disease, but haemorrhagic symptomsand other life threatening manifestations are rare.


The virus can be carried by several species of mosquito, butthe vector in Italy and in recent epidemics elsewhere <nobr>. . .</nobr> [Full text of this article]

Jo Lines, reader in vector biology and malaria control

London School of Hygiene and Tropical Medicine, London

http://www.bmj.com/cgi/content/extract/bmj.39342.563310.80v1

 

[Sally Furniss]

Re: Italy battles imported viral chikungunya epidemic

http://timesofindia.indiatimes.com/...ikungunya_to_Italy/rssarticleshow/2388094.cms

An Indian tourist, visiting relatives in Castiglione town of Italy's Ravenna province, has been found responsible for the outbreak.

Experts from the European Centre for Disease Control who spoke to TOI from Stockholm said: "Just before visiting Italy, the Indian tourist travelled across Kerala, one of the worst affected states with chikungunya, where he was bitten and infected by the local Aedes Albopictus mosquitoes."

The outbreak has raised serious concerns that the disease might soon turn into an epidemic across Europe. Officials fear that the tiger mosquitoes that carry the chikungunya virus will soon infect people in Britain, France, Spain, Croatia and Switzerland.

What's worrying scientists most is that the present outbreak in Italy, which has till now infected 78 people, is being caused by local mosquitoes, who have got infected. This is the first time in history that local transmission of chikungunya disease, not just importation, has taken place anywhere in Europe. Officials believe that this is the first instance that an outbreak of the disease was confirmed outside the tropics.

Ben Duncan from ECDC said: "In the next few weeks, winter will set in several parts of Europe and mosquitoes will get less active. We, however, fear outbreaks in several parts of Europe next year."

He added: "By looking at the recent outbreaks in Asia and Africa, we know that it's a matter of time before mosquitoes all across Europe get infected by the virus and pass it on to humans. We have therefore started to make doctors all over Europe aware about chikungunya and keep it in mind as a possible diagnosis for patients showing classical symptoms like high fever, severe joint pains, red eyes and itchy skin lesions."

According to Italian experts, chikungunya virus has been isolated from local tiger mosquitoes confirming that local transmission has occurred.

 

[Gert van der Hoek]

Re: Italy battles imported viral chikungunya epidemic

Archive Number 20071031.3534
Published Date 31-OCT-2007
Subject PRO/EDR> Chikungunya - Italy (Emilia Romagna) (07)

CHIKUNGUNYA - ITALY (EMILIA ROMAGNA) (07)
*****************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

Date: 17-21 Sep 2007
Source: Chikungunya in Italy Joint ECDC/WHO Mission Report [edited]
http://www.ecdc.eu.int/documents/pdf/071020_CHK_report.pdf


1. Background

On 30 Aug 2007, the Italian Ministry of Health notified, through the Early
Warning and Response System (EWRS) and under the revised International
Health Regulations [IHR(2005)], the EU Member States, the European Centre
of Disease Prevention and Control (ECDC) and the IHR contact point of the
World Health Organization (WHO) regional office for Europe, about a
laboratory confirmed outbreak of chikungunya fever in the region of
Emilia-Romagna in north eastern Italy. At the time of notification, 131
suspected cases had occurred since the 1st (then known) case with onset of
symptoms on 4 Jul [2007]. The majority of cases were reported from 2
neighbouring small villages (Castiglione di Ravenna and Castiglione di
Cervia) in the province of Ravenna.

3. Main findings

3.1. Epidemiological situation

Time line: epidemic curve

Between 15 Jun and 21 Sep [2007], a total of 292 suspected cases were
reported, 125 of whom had been confirmed at the time of the visit. The
chikungunya outbreak started in Castiglione di Cervia and Castiglione di
Ravenna, 2 small neighbouring villages in the province of Ravenna,
separated by a small river. These villages are situated 6 km [3.7 miles]
from the Adriatic coast, and together have a population of 3767. The index
case of the epidemic is resumed to be a resident of the region, who
travelled to the State Kerala, India, in June 2007, and presented with 2
episodes of fever on 15 Jun and 23 Jun [2007]. During the 2nd fever
episode, he visited his cousin in Castiglione di Cervia for several hours.
The cousin, the 2nd reported case, had an onset of symptoms on 4 Jul
[2007]. The epidemic curve shows the presumed index case with onset of
symptoms on 15 Jun [2007], followed by waves of subsequent cases,
compatible with a secondary vectorborne transmission.

Geographical extent

The outbreak spread throughout the 2 villages of Castiglione di Cervia and
Castiglione di Ravenna, affecting residents and a small number of persons
who came to visit family or friends. However, since the end of August
[2007], cases with no known potential exposure in the 2 Castiglione
villages have been reported, providing evidence of local transmission in
adjacent areas. These include, based on the currently available
information, Cervia, Cesena, Ravenna and Rimini where one confirmed case
was reported with onset of symptoms on 12 Sep [2007]. In addition, in spite
of strong vector control activities, transmission of chikungunya virus was
still ongoing during the 3rd week of September in the original 2 affected
villages of Castiglione di Cervia and Castiglione di Ravenna, where a few
recent, confirmed cases had been reported (date of onset 6 Sep [2007]). A
total of 10 additional suspected cases have been reported from 3 other
regions, but all travelled to Emilia-Romagna and were therefore potentially
exposed there. These cases, awaiting lab confirmation, are not included in
the total reported.

Persons affected

The median age of cases is 59 [years] for confirmed cases, ranging from 3
to 95, and 53 for suspected cases, ranging from 1 to 92. This apparent
over-representation of older persons is potentially explained by the rural
nature of the two initial villages where most cases occurred. However, a
reporting bias (older people seeking medical care more often), a severe
clinical presentation or a higher exposure to mosquitoes in this age group
cannot be excluded. The M/F sex ratio is 0.83. The symptoms presented by
the confirmed cases are similar to those presented by cases during the
outbreak in La Reunion, with 95 per cent having arthralgia. One 83 year old
patient, presenting with underlying conditions, died. One patient is
currently comatose; both PCR tests for viral RNA in the liquor turned out
negative.

Entomological situation

_Aedes albopictus_ in Italy
In response to the reported presence of _Aedes albopictus_ in Genoa
(Liguria region) in 1990, a surveillance and control programme was
established by the Ministry of Health, under the coordination of the ISS.
In 1992, the establishment of _Aedes albopictus_ in the Veneto region was
traced back to the importation of used tires from Atlanta, GA, in the USA.
The tiger mosquito then reached other Italian regions through gradual
colonization of the bordering areas and through short and long distance
passive transfer of eggs or different mosquito evolution stages. Guidelines
for the control of _Aedes albopictus_ were issued by the Ministry of health
in 1994. _Aedes albopictus_ was 1st reported in Rome in 1997. In 1998, it
was established in 22 Italian provinces in 9 different regions.

_Aedes albopictus_ in Castiglione di Cervia and Castiglione di Ravenna
In March 2005, all municipalities of the Emilia-Romagna region received the
guidelines for the control of tiger mosquitoes. _Aedes albopictus_ is known
to be present in the 2 Castiglione villages since 2006. The 2 villages are
separated by a river with relatively stagnant water resulting from the
presence of a lock. Conditions around the houses seem optimal for vector
development and expansion. Houses are typically low (ground and second
floor), surrounded by small gardens with many flowers, plants and flower
pots. In the streets, drainage systems are visible, reflecting open
stagnant water underground.

The available data indicated an increase of vector presence in the area
over the recent years corresponding to the establishment of the vector in
the area, and reached a plateau level in 2007. The favourable conditions
for local transmission were present in the 2 Castiglione villages, and it
is very likely that such conditions exist in other areas of the Ravenna
province and Emilia-Romagna region. The appearance of new cases in Ravenna,
Rimini and Cesena, who had no history of exposure to the initially affected
area, suggests that transmission has spread through infected mosquitoes to
at least 3 urbanized areas. This finding needs to be taken into account in
the risk assessment, surveillance and response to the outbreak.

Mosquito activity is expected to continue until the end of October [2007],
but may extend into November according to the weather conditions. However,
even if no adult mosquitoes circulate during winter time, the recent
evidence of trans-ovarian (vertical) virus transmission gained from studies
done in la Reunion possibly increases the risk for re-appearance of
infected mosquitoes in the spring of 2008. Timely detection of this
potential re-appearance through surveillance, with rapid implementation of
vector control measures in close collaboration with the local population,
will be essential to control a potential recurrence of the virus in 2008.

Control measures implemented

Since 18 Aug [2007], vector control measures have been implemented in the 2
villages of Castiglione di Cervia and Castiglione di Ravenna, and were
gradually extended according to the progress of the outbreak. Measures
include both the control of breeding sites and the use of insecticides. In
addition to targeting public areas, door-to-door control activities are
implemented within a radius of 100m around each suspected case, or within a
radius of 300m [328 yards] around every cluster of cases. Private companies
carry out the vector control measures, under the supervision of
entomologists of the regional public health service.

Blood donation

On 31 Aug [2007], blood donation from people living in the municipalities
of Ravenna and Cervia was suspended "till new order" through a ministerial
circular. In addition, blood donation was suspended from people who stayed
in affected areas for 21 days after leaving the area. On 3 Sep [2007],
exclusion measures were extended to Cesena and Cesenatico.

Risk assessment for Europe

The current outbreak of chikungunya in Italy is the 1st documented
vectorborne transmission of the virus in continental Europe. The
autochthonous transmission has extended beyond the initial 2 villages,
resulting in the establishment of at least 3 secondary transmission foci by
local mosquitoes. In addition, the transmission in the 2 initial villages
had not yet ceased at the time of our visit, more than 2 months after the
initial case occurred. The importance of this event should not be
underestimated and its comprehensive documentation is crucial to ensure a
maximal benefit to control its spread and for future preparedness in case
of similar occurrences of mosquito-borne disease transmission, in Italy and
elsewhere.

Risk for sustained virus transmission of Chikungunya virus in Italy
Several factors seem to have contributed to the establishment of local
transmission in continental Europe:
- the presence in high density of _Aedes albopictus_ in an area of the
Emilia-Romagna region where it had appeared relatively recently and was
therefore not yet covered by the vector monitoring system;
- an ecological situation favourable for the development of the vector and
for virus transmission, considering the dense local vegetation and domestic
backyards with plant pots and potential water containers in the 2 villages;
- the introduction of the virus by a visitor returning from a chikungunya
high endemic area;
- sufficient (human) population density.

Based on the available data, it is likely that the transmission of
chikungunya virus will persist in the coming weeks, probably until the end
of October 2007 when the local vector activity should disappear. This may
result in additional chikungunya fever cases occurring and being reported
until then. It cannot be excluded that, in case of a particularly mild
winter, local vector activity may persist during winter, especially in
urban settings, potentially resulting in few sporadic cases which would,
however, maintain mosquito-to-human transmission cycles until the spring.
In addition, considering the existence of vertical (trans-ovarian)
transmission, reported "in natura" in a tropical region, mosquitoes
infected with Chikungunya virus may re-appear in the spring of 2008, when
mosquito eggs hatch and vector activity starts again after the winter.

--
communicated by:
Roland Hubner
Scientific Collaborator
Health Council, FPS Public Health
Belgium
<roland.hubner@health.fgov.be>

[ProMED-mail thanks Dr Hubner for bringing this report to our attention.
Readers interested in seeing the full report and its figures, can access it
at the above URL. This report, and its recommendations, will be of
particular interest to public health officials in countries where _Aedes
albopictus_ has become endemic. A map of the Emilia Romagna region and its
location in Italy can be accessed at
http://www.knowital.com/italy/maps/emiliaromagnamap.html. - Mod.TY]

http://www.promedmail.org/pls/prome..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,39882

 

[Gert van der Hoek]

Re: Italy battles imported viral chikungunya epidemic

Archive Number 20071210.3980
Published Date 10-DEC-2007
Subject PRO/EDR> Chikungunya - Italy (Emilia Romagna) (08)

CHIKUNGUNYA - ITALY (EMILIA ROMAGNA) (08)
*****************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

[The following article in Eurosurveillance provides the latest, and
probably final, summary of the 2007 chikungunya virus epidemic in
Italy. With this article, and the onset of winter[ending the mosquito
sesason], this thread is cut. - Mod.TY]

Date: Thu 22 Nov 2007
Source: Eurosurveillance weekly release, 2007 12(11) [edited]
<http://www.eurosurveillance.org/ew/2007/071122.asp#2>


Laboratory results
------------------

The 1st outbreak of autochthonously transmitted
chikungunya virus (CHIKV) in Europe, which
recently occurred in the province of Ravenna in
north-eastern Italy [1,2], has been completely
controlled: the last case's onset occurred on 28
Sep [2007] in the town of Rimini, and in October
no cases were confirmed. Of the 334 suspected or
probable CHIKV cases involved in the outbreak,
samples were examined of 281 and 204 were
laboratory-confirmed by PCR [polymerase chain
reaction], hemagglutination-inhibition, or both.
Reasonably, the number of laboratory-confirmed
cases most likely constitutes an underestimate of
the extent of the outbreak, since blood or serum
samples were not available for all of the
individuals who fulfilled the clinical and/or
epidemiological criteria of the case-definition.

Geographical distribution of cases
-----------------------------------

Most cases were reported among persons living in
or visiting the initially affected villages of
Castiglione di Cervia and Castiglione di Ravenna.
Also detected were 4 smaller clusters of local
transmission in 4 towns in the same region (that
is, Cervia, Cesena, Ravenna, and Rimini), which
are located 9 to 49 km (5.6-30 mi) from the
initially affected villages. For at least 3 of
the 4 clusters, population movement (that is,
persons who visited the area that was primarily
affected or persons from the primarily affected
area who visited one of the 4 towns) can be
reasonably assumed to have been the main
determinant of local transmission. However, if
this was the case, the question arises as to why
no previous outbreaks of CHIKV occurred in other
Italian regions in 2005-2006 (after the epidemic
in Reunion), when at least 30 infected travellers
returned to locations infested by mosquito vector
populations [3]; the same question arises for
several hundred cases reported among travellers
returning from affected areas to a number of
European countries in the same period [3,4,5].
Possible explanations include: i) high
concentration of vectors in the affected towns;
ii) highly viremic persons exposing themselves to
aggressive _Aedes albopictus_ populations as a
consequence of the structures of houses and/or
behavioural factors (such as, spending time
outdoors in houses' surroundings).

Overall, the epidemic in Italy can be said to be
the result of the combined effect of the
globalisation of vectors and humans, which
occurred through a 2-step process: i) the
introduction and adaptation of the vector _Ae.
albopictus_ to a new environment (that is, a
temperate climate); and ii) the introduction of
CHIKV in a previously infection-free country,
with totally susceptible subjects, as the result
of population movement (that is, travelling human
hosts, acting as a sort of Trojan horse).
However, the epidemic was limited in space and
time, with a marked decay rate since the adoption
of appropriate control measures (albeit they were
taken at different times in different locations).
In addition, there is probably a time-limited
capacity of the vector to sustain infection
transmission beyond the hot season in a country
with a temperate climate.

What did we learn from the Italian epidemic?
--------------------------------------------

- Vector-borne diseases, historically confined to
tropical environments, can be introduced within
Europe if the conditions are appropriate (that
is, the presence of vectors). The major
determinant of the outbreak in Italy was probably
the high vector density at the time of arrival of
the index case, which could be explained by the
lack of preventive vector-control measures in an
area that was considered to be 'infection-free';

- The vectorial capacity of _Ae. albopictus_ for
CHIKV is high [6]. A few hours spent in a highly
vector-dense village by only one feverish patient
caused a large outbreak in a naïve population;

- As seen for other infectious diseases causing
international crises (that is, SARS), population
movement and vector colonisation of new areas are
important determinants of disease globalisation.

Nonetheless, there are still some questions that
need to be investigated further:

- Why did a single case result in an outbreak
while none of the many CHIKV-infected travellers
have caused local transmission upon returning
home to Italy or other European countries in
roughly similar vector-dense areas;

- Has the infection been eradicated in the
affected area or could it reappear at the
beginning of the next hot season due to
overwintering [by infected mosquitoes]?

- What is the probability that other similar
events will occur in Italy or other European
countries where _Ae. albopictus_ is present, and
could other infections, such as dengue, cause
similar outbreaks in Europe?

These questions need to be adequately answered so
as to strengthen activities for the surveillance
and control of _Ae. albopictus_ and other vectors
of exotic infectious diseases (that is,
chikungunya and others) and to perform early
diagnosis of viral agents that can be imported
and transmitted in Europe. Furthermore, more
intense research efforts should be promoted in
Italy and in Europe on the mosquito-virus
relationship, as well as in other critical areas
concerning vaccine and specific antiviral drugs.
Experimental infections in vector populations,
virus and vector genotyping are some of the
specific investigations already planned in Italy.

References
----------

1. Angelini R, Finarelli AC, Angelini P, Po C,
Petropulacos K, Macini P, Fiorentini C, Fortuna
C, Venturi G, Romi R, Majori G, Nicoletti L,
Rezza G, Cassone A: An outbreak of chikungunya
fever in the province of Ravenna, Italy. Euro
Surveill 2007; 12(9): E070906.1. Available from
<http://www.eurosurveillance.org/ew/2007/070906.asp#1>

2. G Rezza, L Nicoletti, R Angelini, R Romi, AC
Finarelli, M Panning, P Cordioli, C Fortuna, S
Boros, F Magurano, G Silvi, P Angelini, M
Dottori, MG Ciufolini, GC Majori, A Cassone:
Infection with Chikungunya virus in Italy : An
outbreak in a temperate region. Lancet, 2007, in
press.

3. Nicoletti L, Ciccozzi M, Marchi A, Fiorentini
C, Martucci P, D'Ancona F, Ciofi degli Atti M,
Pompa MG, Rezza G, Ciufolini MG: Correlates of
Chikungunya and Dengue in travellers. Emerging
Infectious Diseases, in press.

4. Depoortere E, Coulombier D, ECDC Chikungunya
risk assessment group: Chikungunya risk
assessment for Europe: recommendations for
action. Euro Surveill 2006; 11(5): E060511.2.
Available from
<http://www.eurosurveillance.org/ew/2006/060511.asp#2>

5. Joint ECDC/WHO European Risk Assessment on
Chikungunya in Italy: a mission report. Available
from
<http://www.ecdc.europa.eu/pdf/071030CHK_mission_ITA.pdf>

6. Vazeille M, Jeannin C, Martin E, Schaffner F,
Failloux AB: Chikungunya: A risk for
Mediterranean countries? Acta Trop. 2007 Oct 12;
[Epub ahead of print].

--
[R Angelini (1), AC Finarelli (2), P Angelini
(2), C Po (2), K Petropulacos3 G Silvi (1), P
Macini (2), C Fortuna (4), G Venturi (4), F
Magurano (4), C Fiorentini(4), A Marchi (4), E
Benedetti (4), P Bucci (4), S Boros (4), R Romi
(4), G Majori (4), MG Ciufolini (4), L Nicoletti
(4), G Rezza (4), A Cassone <cassone@iss.it> (4)

1. Dipartimento Sanita Pubblica, Azienda Unita
Sanitaria Locale (Department of Public Health,
Local Health Unit), Ravenna, Italy

2. Servizio di Sanita Pubblica, Regione Emilia-Romagna, Bologna, Italy

3. Servizio Presidi Ospedalieri, Regione Emilia-Romagna, Bologna, Italy

4. Department of Infectious, Parasitic and Immunomediated Diseases,
Istituto Superiore di Sanita, Rome, Italy]


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