ISSUE REPORT WEST NILE VIRUS: 2004 Expected to Be Most Severe Year Yet Source: Health Canada’s West Nile virus Web site, Health Canada, http://www.west- nilevirus.gc.ca. © Her Majesty the Queen in Right of Canada, represented by the I n five years since its first U.S. discovery in New York City in 1999, West Nile virus (WNV) has become a permanent part of the U.S. health landscape. The 2003 WNV season was the most severe ever. Nearly 10,000 Minister of Health (2003). people contracted the disease, which emerges each spring and peaks in the summer and early fall. 2003 WNV activity was concentrated in the Midwestern, Plains, and Rocky Mountain states, though human cases were diagnosed in 45 states and the District of Columbia.1 The Centers for Disease Control and Now that WNV has established a strong TRUST FOR AMERICA’S HEALTH IS Prevention (CDC) predicts that the 2004 foothold in the U.S., public health measures A NON-PROFIT, NON-PARTISAN West Nile season will be especially haz- should reflect the changing nature of the ORGANIZATION DEDICATED TO ardous, with case counts expected to exceed disease and its potential impacts. SAVING LIVES BY PROTECTING 2003’s total. Health officials also project T H E H E A LT H O F E V E RY that, for the first time, WNV will have a sig- WNV raises the following public health COMMUNITY AND WORKING TO nificant impact on the West Coast in 2004. concerns: The disease, which is spread to humans by I How to protect people most at-risk to MAKE DISEASE PREVENTION A infected mosquitoes, has moved westward in develop symptoms and complications NATIONAL PRIORITY. the U.S. with each successive season. from the virus, particularly those with Early indications show that these projec- compromised immune systems, includ- tions are on-target – this year’s first con- ing: the elderly, cancer patients undergo- firmed human cases have mostly emerged in ing chemotherapy, and people with HIV. the Plains states and far Western United N Additionally, though investigations are States, in residents of Arizona, California, preliminary at this time, there is con- Nebraska, New Mexico, South Dakota, and cern that there may be a possible link Wyoming, in addition to two cases in between WNV and birth defects. In Florida2 In California, WNV has been dis- 2002, a pregnant woman contracted JULY 2004 covered in Imperial, Los Angeles, Orange, West Nile virus and later gave birth to a PREVENTING EPIDEMICS. Riverside, San Bernardino, and Ventura child with several birth defects, who PROTECTING PEOPLE. counties as of June 24.3 also tested positive for WNV.4 I How to help communities evaluate the WNV season, 2.5 million blood donations health risks or benefits of mosquito-reduc- were screened for WNV, leading to the tion strategies, including spraying of chem- removal of over 800 infected donations.6 icals that may raise other health concerns. In this white paper, Trust for America’s Health I How to diminish the hazard WNV poses (TFAH) will review the history and impact of to nationwide blood banks. In 2003, six West Nile virus, assess current control and pre- cases of WNV were attributed to blood- vention strategies, and offer recommenda- bank transmission, following 23 cases in tions to improve our national readiness 2002.5 During the height of the 2003 against WNV and other emerging diseases. Tracing WNV’s Spread, 1999-2003 In five short years, West Nile virus has with the continued prevalence in the rest of evolved from an isolated municipal event the country, makes the 2004 season an espe- into a full-blown national epidemic. The cially dangerous prospect. projected West Coast emergence, combined West Nile Virus Human Case Count in U.S., 1999– 2003 12000 9862 10000 8000 6000 4156 Human Case 4000 Count 2000 62 21 66 0 1999 2000 2001 2002 2003 2 As the following images from CDC demonstrate, WNV has moved steadily westward with “WEST NILE IS NOW WELL each season.7 ESTABLISHED IN AMERICA . UNPREDICTABILITY IS THE ONLY THING PREDICTABLE ABOUT NEW INFECTIOUS DISEASES. THE QUICK EMERGENCE AND SPREAD OF WEST NILE IS A REMINDER THAT WE MUST West Nile Virus Activity West Nile Virus Activity I Non-human WNV Activity I Non-human WNV Activity I Human WNV Activity I Human WNV Activity PROACTIVELY PLAN FOR National Center for Infectious Diseases National Center for Infectious Diseases THE UNEXPECTED.” WEST NILE VIRUS ACTIVITY WEST NILE VIRUS ACTIVITY Cumulative results for 1999 calendar year Cumulative results for 2000 calendar year – LOUIS W. SULLIVAN, Former Secretary of the U.S. Department of Health and Human Services West Nile Virus Activity West Nile Virus Activity I Non-human WNV Activity I Non-human WNV Activity I Human WNV Activity I Human WNV Activity National Center for Infectious Diseases National Center for Infectious Diseases WEST NILE VIRUS ACTIVITY WEST NILE VIRUS ACTIVITY Cumulative results for 2001 calendar year Cumulative results for 2002 calendar year States and Counties Reporting WNV Activity, United States, 1999-2003* Year # States # Counties Date Range 1999 4 28 9 Aug – 15 Nov 2000 12** 145 6 Feb – 17 Nov 2001 27** 359 8 Apr – 26 Dec West Nile Virus Activity 2002 44** 2,531 3 Jan – 19 Dec I Non-human WNV Activity I Human WNV Activity 2003 46** 2,289 1 Jan – 12 Dec National Center for Infectious Diseases WEST NILE VIRUS ACTIVITY * Reported to ArboNET as of 1/20/2004 Cumulative results for 2003 calendar year ** Plus D.C. 3 History of West Nile Virus W est Nile virus (WNV), first identified in Uganda in 1937, infects humans, birds, and horses. WNV is a type of virus that causes encephalitis, or inflammation of the brain. The virus has been confirmed in Africa, western Asia, the Middle East, the Mediterranean region of Europe and, since 1999, the U.S. In people, most infections produce no then transmit WNV to humans and animals symptoms, or mild to moderate symptoms. through biting. Testing for the virus in An estimated 20 percent of people infected humans involves collection of blood and will develop West Nile fever. Symptoms may cerebrospinal fluid to determine the pres- include headache, fever, and body aches, ence of antibodies to the virus. The incuba- often with skin rash and swollen lymph tion period is generally five to 15 days from glands. More severe infections may be the time a mosquito carrying WNV infects marked by high fever, neck stiffness, muscle an individual. weakness, stupor, disorientation, convul- There is no specific therapy for treating sions, paralysis, coma, and, rarely, death. WNV. In more severe cases, intensive sup- The elderly, the very young, and individuals portive therapy may be necessary such as with weakened immune systems are most hospitalization, intravenous (IV) fluids, air- likely to develop West Nile fever. way management, respiratory support (ven- WNV exists through a transmission cycle tilator), and prevention of secondary infec- involving mosquitoes and birds. Mosquitoes tions (pneumonia). Currently, no vaccine become infected with the virus when they to prevent WNV in humans is available, feed on infected birds, which carry the virus although clinical trials for such a vaccine are in their blood. Infected mosquitoes can underway. A vaccine for horses is available. CALIFORNIA’S VULNERABILITY Beyond the previously noted westward migration of WNV, California is projected for a severe West Nile season in 2004 due to several factors: the state has a prevalence of agricultural areas with well-irrigated fields and a predominance of polluted urban waterways, both breeding grounds for multiple types of WNV-carrying mosquitoes. Additionally, California’s population density ensures high volume interactions with mosquitoes. In preparation for the onset of WNV, state health officials, working in concert with CDC, have been engaged in several preventative health measures focused on mosquito-population control and public education.8 However, a recent report by the RAND Corporation found California’s public health agencies are not uniformly prepared to respond to disease outbreaks and other important challenges – a dangerous development in a state certain to be impacted heavily by WNV.9 “We certainly have all the ingredients here in California for a major outbreak that involves two or three different species of mosquitoes, where a lot of states may have just had to worry about one”10 –Dr. John Edman, Director of University of California Davis Center for Vectorborne Diseases 4 Emergence of WNV In August 1999, wild birds, especially crows, and human cases were indeed related. began dying in significant numbers in New WNV is in the same family as SLE. The U.S. York. Several residents of New York City public health community was shocked at the contracted encephalitis and, a month later, discovery of WNV, previously found only in horses on Long Island were showing signs Africa, the Middle East, and Europe. The of illness. outbreak ended in the fall of 1999, but not before 62 people developed severe Originally, a public health laboratory and the encephalitis, including 59 requiring hospi- CDC identified the human cases as St. Louis talization, and seven who died.11 encephalitis (SLE), the most common mos- quito-borne disease in the U.S. The dead The lack of coordination between the ani- birds, rarely killed by SLE, were not believed mal and public health communities resulted connected to the human cases. Dr. Ian in a series of setbacks in identifying the true Lipkin, currently at the Columbia University’s cause of the outbreak. This slowed the Mailman School of Public Health, was the disease containment and public education first scientist to publish a paper identifying efforts in the important early stages when the disease as West Nile virus. time can mean the difference between con- taining an outbreak and the exponential Two weeks later, CDC changed its diagnosis spreading of the illness. to WNV. The two seemingly distinct animal COLORADO’S WNV EPIDEMIC In 2003, Colorado had more reported cases of WNV and related deaths from the virus than any other state. Colorado reported 2,947 cases, compared to Nebraska’s 1,942, the state with the second highest number of cases. Sixty-one Colorado residents died after being infected. Over 20 percent of Colorado’s cases developed into “neuroinvasive diseases,” serious illnesses that affect the nervous system such as WN encephalitis and WN meningitis. These diseases cause inflammation in the brain (encephalitis) and of the membrane surrounding the brain and the spinal cord (meningitis), and can be fatal. State budget cuts made the fight against WNV difficult in some parts of Colorado like Larimer County – one of the areas hardest hit by the virus. In 2002, the Larimer County Department of Health and Environment received $100,000 in federal public health preparedness money, but lost $700,000 due to state cuts. This budget reduction forced the county to reduce staff and cut a range of services. In the summer of 2003, this weakened agency faced a monumental chal- lenge: more than 500 county residents were infected with West Nile Virus. Lack of resources delayed the county’s ability to fight back.12 5 Public Health Response to West Nile Virus • INTERAGENCY COLLABORATION AND COOPERATION • TRACKING AND SURVEILLANCE SYSTEMS • LABORATORIES AND TESTING CAPACITIES Interagency Collaboration and Cooperation After the 1999 WNV outbreak, CDC created WNV with input from a variety of scientists a West Nile Interagency Working Group, and public health professionals, including which facilitates information sharing and virologists, epidemiologists, laboratory per- coordination of activities among the range sonnel, wildlife biologists, and state and of agencies that have some connection to local health and agriculture officials. The disease and wildlife control. CDC also developed tests for use at state lab- oratories to diagnose WNV in humans, and In 2000, CDC began publishing guidelines provided training on how to use them. for surveillance, protection, and control of AGENCIES AND ORGANIZATIONS INVOLVED IN RESPONDING TO WEST NILE VIRUS U.S. Department of Health and U.S. Department of Commerce Human Services (HHS) • Conducts research on the impact of climate • CDC is in charge of disease outbreak patterns on mosquito populations and helps investigations, tracking, and diagnosis develop plans for mosquito control. efforts, including management of the Interagency Working Group. U.S. Department of Defense • CDC operates ArboNET, the electronic • Conducts research and testing initiatives to surveillance system for tracking mosquito- prepare and treat the military and public. borne infections. • Tests the impact on the Armed Service • Food and Drug Administration (FDA) Blood Program. protects against the risk of contaminating Environmental Protection Agency the nation’s blood supply. • Researches and tracks the impact of pesti- • National Institutes of Health (NIH) cides used in prevention efforts. engages in research and testing of the virus and develops related treatments. U.S. Department of the Interior U.S. Department of Agriculture • Assists states with diagnosis of wildlife infections. • Tracks WNV’s impact on U.S. livestock and poultry. • Oversees control and prevention measures in National Park land. • Conducts research to develop methods for surveillance, monitoring, prevention, State and local public health, agriculture, and control among animal populations. environmental protection, and wildlife agencies also work to control WNV. 6 Tracking and Surveillance Systems “WEST NILE VIRUS CAN BE West Nile tracking is performed through The isolated nature of ArboNET, however, SEEN AS A HARBINGER OF CDC’s “ArboNET,” an electronic surveil- means that key linkages to other disease pat- THINGS TO COME. IF WE lance system that monitors WNV and other terns and contributing health, behavioral, BETTER PREPARED OUR mosquito-borne illnesses. The tracking sys- and environmental factors, which are all PUBLIC HEALTH SYSTEM tem facilitates information-sharing between invaluable to effective disease prevention, CDC and numerous state and local public are not being made. Currently, there is not WITH THE TRAINED health agencies across the U.S. a nationwide health tracking network that WORKFORCE, TECHNOLOGY, coordinates the monitoring of diseases and Disease surveillance is a vital tool in helping AND CONTINGENCY connects them to possible related factors. public health officials to understand how to PLANNING AND FLEXIBILITY This type of information would help control and prevent disease. ArboNET allows researchers gain a better understanding IT NEEDS, WE WILL DO A states to track crows and other wildlife impact- about which portions of the population are ed by WNV, in addition to humans. Wildlife BETTER JOB OF PROTECTING most at-risk, and learn more about the caus- provide a key indicator for tracking the THE PUBLIC FROM THE es and ways to control diseases. spread of the disease and demonstrating the NEXT DEADLY DISEASE crucial and valuable need to connect human and animal health efforts. WE ENCOUNTER.” – ALLAN ROSENFIELD, MD, Dean of the Mailman School of Public Health at Columbia RIFT VALLEY FEVER. THE NEXT WEST NILE? University. Like West Nile virus, Rift Valley fever is a mosquito-borne disease native to Africa that is begin- ning to spread beyond the continent. Since 2000, cases of Rift Valley fever have been diagnosed in Yemen and Saudi Arabia, where approximately 100 persons died.13 The transmission cycle is similar to West Nile virus, through infected mosquitoes or through contact with infected animals (usually livestock). Past Rift Valley outbreaks in Africa have shown that the disease can result in deadly hemorrhaging fevers and brain inflammations in a small number of humans.14 Though death rates have varied widely in past human outbreaks, health officials worry that Rift Valley fever would have a significantly higher mortality rate than West Nile virus.15 The presence of American servicepersons in the Middle East, in addition to the increasingly interconnected globe, makes common sense mosquito bite prevention against Rift Valley a logical precaution. “If we get Rift Valley fever in the United States, it would make West Nile look like a hiccup” -Dr. Corrie Brown, Member of U.S. Secretary of Agriculture’s Advisory Committee for Animal and Poultry Diseases in Associated Press article.16 7 Laboratories and Testing Capacity Laboratory testing is needed before a case vided all states with testing solutions, specif- can officially be classified as WNV. Lab tests ically the reagents, to ensure cost-effective, most often measure antibodies to WNV in high quality, and comparable results. the blood of potential infected individuals.17 However, the virus moved more rapidly and virulently than anticipated, eventually over- Most state labs are now self-sufficient in test- whelming lab capacity and reagent supply. ing for WNV using the IgM antibody test. In This failure to prepare for “surge capacity” the past, CDC tested every positive sample violated the fundamental rule of planning in its national labs for confirmation, but for worst-case contingencies when dealing now CDC acts in an advisory capacity and is with new and emerging infectious diseases. prepared to offer testing and clinical assis- tance when called upon by laboratories.18 For 2004, CDC has contracted with Focus Re-testing of initial positives occurs when Technologies, a Virginia-based firm, to pro- the patient may have been exposed to close- vide private-sector assistance in order to ly related viruses like SLE or to confirm avoid the planning failures of the previous results from an insufficient sample size.19 year. However, the 2003 reagent shortage illustrates a larger problem: the continued Increasingly, state labs contract with private emphasis on reactive shortcuts instead of a laboratories to handle the volume of testing, true investment in proactive solutions. By using procedures modeled after CDC test- institutionalizing flexibility, backup plans, ing protocols.20 The Association of Public and a wider-range of public-private partner- Health Laboratories (APHL), state health ships, CDC and the public health system in departments, FDA, and CDC monitor com- general will be sure to avoid the persistent mercial testing procedures to ensure suit- pitfalls of reactive planning, as illustrated by able standards of accuracy.21 the control and containment approach to To prepare for the 2003 season, CDC’s Fort West Nile. Collins, CO manufacturing laboratory pro- PUBLIC HEALTH LABORATORIES OVERVIEW Public health laboratories consist of a loose network of federal, state and local laboratories that work in undefined collaboration with private clinical laboratories. They are responsible for a range of emergency response, disease surveillance, and specialized testing procedures.22 CDC rests atop the loose network of public health laboratories. CDC’s lab is the only civilian laboratory in the country with comprehensive capacity to test for the presence of toxic chem- icals in the human body.23 Below the CDC, each of the 50 states (and the five territories) has a state public health laboratory (SPHL). State laboratories are not uniform in their capabilities, functions, or resources.24 Each state lab was created and operates independently under its state-defined charter and, consequently, varies widely from location to location. Many labs lack the capacity to continually monitor infec- tious agents or prepare for chemical or biological terrorism and face inadequate staffing and equipment concerns.25 8 Trust for America’s Health Recommendations W est Nile virus is now an unfortunate national reality. The focus of public health efforts should be shifted in acknowledgement of the disease’s permanence. The long-term impact of mass mosquito spray- American Medical Association, and ing on the human population-at-large is still the American Nurses Association to relatively unclear and needs much more encourage health professionals to examination. Additionally, the initial need for alert vulnerable patients to the impor- massive information gathering and research tance of taking precautions against centered on the testing of infected bird WNV infection. species should be moderated in favor of pre- In addition, CDC should work with ventative education and control measures cen- the American College of Obstetricians tered on common sense and self-protection. and Gynecologists and other health Specifically, emphasis should be placed on: care practitioners to raise awareness I Education. Preventative measures, about WNV among pregnant women. such as CDC’s ongoing “Fight the While the effect of WNV infections Bite!” campaign are essential to effec- during pregnancy is not fully under- tive control of WNV. Awareness and stood, one case reported case in 2002 education initiatives, such as eliminat- suggests that intrauterine transmission ing stagnant water around your home of WNV in certain instances might and wearing insect repellent, are the affect the newborn adversely.26 CDC most cost-effective and efficient has issued advice to pregnant women means of controlling the impact of who live in areas with WNV-infected WNV. (See sidebar for CDC Individual mosquitoes (See box). Recommendations). I Contingency Plans for Individual CDC has done an admirable job in Blood Donation Testing in Areas with communicating common-sense pre- High Rates of WNV Infection. In July vention strategies through Web sites, 2003, blood collection centers began multilingual public service announce- testing the blood supply for WNV ments, and informational materials using a sophisticated method called targeted to public health profession- nucleic acid technology (NAT). This als, media representatives, and the testing method detects minute general public. amounts of the genetic material of the virus in a person’s blood. After a per- However, CDC and HHS could do son is infected with WNV, relatively more to educate the most vulnerable high levels of the virus remain in their populations: very young children, the blood for an average of 6.5 days.27 elderly, and people with weakened During this timeframe, an individual immune systems. CDC should work who donates blood could transmit the with medical organizations such as the infection to a recipient. American Academy of Pediatrics, the 9 Currently, blood centers have tested mission of WNV in 2003, the two WNV- “minipools” of blood, a batch of 6 to 16 contaminated blood donations that led donations. If the test finds no virus to the transmission had screened nega- present, then it is used. However, if the tive during initial minipool testing. When minipool tests positive, the blood of the donations comprising the minipools each individual donor in the pool is were tested individually during a retro- then tested. Given that there are 2.5 spective examination, these two dona- million blood donations a year, it is not tions contained very low levels of WNV. feasible to test all individual donors Blood Centers should have contingency due to expense, and because there plans to test individual donations in areas would be too few trained laboratory that might be experiencing a high num- personnel to conduct the tests. ber of WNV infections. Individual dona- tion testing is being put into place at However, all blood centers should have selected blood banks in Kansas, contingency plans in place for conduct- Nebraska, North Dakota, Oklahoma, and ing individual donor testing using NAT. South Dakota for 2004. In cases of transfusion-associated trans- WNV AND PREGNANCY 28 The potential health risks of West Nile transmission from mother to fetus during pregnancy is not fully understood. While research is being conducted, officials recommend the following preventative options: Common Sense Measures During Pregnancy: Pregnant women who live in areas with WNV-infected mosquitoes should apply insect repellent to skin and clothes when exposed to mosquitoes and wear clothing that will help protect against mosquito bites. In addition, when- ever possible, pregnant women should avoid being outdoors during peak mosquito-feeding times (i.e., usually dawn and dusk). Evaluation of Infants Born to Mothers Infected with WNV During Pregnancy: When an infant is born to a mother who was known or suspected to have WNV infection during preg- nancy, clinical evaluation is recommended. Infants should undergo a physical examination and evaluation for neurological damage or abnormalities. Information From CDC “Fight the Bite!” Web site HOW INDIVIDUALS CAN REDUCE THEIR RISK (According to the CDC) Learn About Mosquito Mosquito-Proof Your Home Help Your Community Control I Drain standing water I Report dead birds to I Apply insect repellent I Install or repair screens local authorities I Be aware of peak I Mosquito control pro- mosquito hours – dusk grams (Information line: to dawn 1-800-858-7378) 10 General Public Health System Improvements “WE NEED TO PLAN FOR THE UNPREDICTABLE IN ORDER TO The public health system’s response to WNV pressing health threats ranging from offers insight into readiness to fight any WNV to bioterrorism. The volume of MEET THE NUMEROUS POTENTIAL emerging infectious disease. As late as the information gathered and cross-refer- CHALLENGES OF THE NEXT 2003 WNV season, public health officials and enced across regional systems would be DEADLY INFECTIOUS DISEASE – policymakers were reactive and shortsighted a cornerstone for rapid control and in control and command planning against the prevention strategies and timely and WHICH IS SURE TO EMERGE spread of WNV – elements that do not bode coordinated responses.30 NEDSS is a BEFORE WE ANTICIPATE.” well for the next emerging infectious disease. step in the right direction, but not – KATHERINE KELLY, enough. A real investment to overhaul In addition to these recommendations, President-Elect, and develop a nationwide health track- combating West Nile virus, as well as other Association of Public ing system is estimated at $275 million. health threats ranging from food-borne ill- Health Laboratories ness to bioterrorism to chronic disease, I Improved Laboratory Facilities: A 2003 (APHL) requires a strong public health infrastruc- TFAH report concluded that our nation’s ture. The following recommendations aim laboratories are unprepared to meet to modernize public health by improving their responsibilities as front-line defend- disease surveillance, laboratory capacity, ers in our battles against the range of and developing a more cohesive national health threats we face.31 A committed system capable of responding to the myriad investment is needed to ensure that labo- of 21st century health threats. ratories at the federal, state, and local lev- els are better prepared for their crucial I Implementing a Coordinated Disease detection and response capabilities. Surveillance System Must be a Specifically, TFAH recommends: Priority. CDC launched the National Electronic Disease Surveillance System N Federal and state public health labo- (NEDSS) in 2000 to integrate numer- ratory capabilities need to be mod- ous surveillance and reporting systems ernized, including upgrading facili- for diseases such as hepatitis, vaccine- ties and equipment and bolstering preventable illness, and tuberculosis in the workforce. This is essential if an effort to simplify disease reporting public health laboratories are to have across different jurisdictions and com- the capability to respond to all health munications systems. Unfortunately, hazards, including the ability to test over 40 states and the District of for antibodies as well as man made Columbia have yet to adopt a NEDSS- biological agents, such as ricin or compatible system, largely due to cyanide. The recommended invest- piecemeal funding at the federal level. ment it will take to achieve this is CDC appropriations for the system $200 million in funding. totaled $28 million in FY 2004, much N CDC should retain and expand its less than the $50 million public health Emerging Infectious Disease officials have recommended.29 Capacity Program to ensure that However, even with greater funding, states have the ability to respond flex- NEDSS represents a stopgap solution ibly and rapidly to an outbreak and masking a deeper problem. The lack of are able to develop contingency a 21st century, integrated disease track- strategic planning for emerging and ing network hinders our ability to meet spreading infectious diseases. 11 I Summit on Public Health Readiness: state and even county to county. It is clear Whether responding to West Nile virus or that the U.S. needs a more cohesive, a bioterrorism attack, the current effort to national public health system. Towards improve the nation’s ability to respond to that aim, the President, in consultation the range of public health emergencies with Congress and public health experts, faces a significant organizational chal- should convene a White House summit lenge. Whatever the threat, the response that will develop a concrete vision for the is largely dependent on the functioning of future of the American public health sys- a patchwork of state and local public tem and the resources needed to make it health agencies, whose funding sources, a reality. The summit would consider how bureaucratic structure, and responsibili- the country can best build a robust, inte- ties can vary significantly from state to grated public health infrastructure. Appendix: DATA FROM CDC’S ARBONET WEST NILE VIRUS DISEASE 2003 HUMAN CASES, BY CLINICAL SYNDROME AS OF APRIL 14, 2004, 3AM MST* These figures represent final numbers for 2003.** # Indicates human disease case(s) Avian, animal or mosquito infections WA ND MT NH (3) (617) MN (222) (149) VT(3) ME SD WI OR ID (1039) (17) WY MI NY (1) (375) (19) (71) MA (17) IA NE (147) (1942) PA (237) RI (7) IL IN OH CT (17) NV UT (54) (47) (108) NJ (34) (2) (1) CO MO WV DE (17) (2947) KS (91) (2) (64) VA MD (73) KY (14) (26) CA DC (3) (3) OK TN (26) NC (24) (79) AR AZ NM (25) (209) SC (6) (13) MS AL GA (87) (37) (50) TX LA (717) (123) FL (94) AK HI *Currently, WNV maps are updated regularly to reflect surveillance reports released by state and local health departments to the CDC Arbonet system for public distribution. Map shows the distribution of avian, animal, or mosquito infection occurring during 2003 with number of human cases if any, by state. If West Nile virus infection is reported to CDC Arbonet in any area of a state, that entire state is shaded accordingly. 12 2004 WEST NILE VIRUS ACTIVITY IN THE UNITED STATES (reported to CDC as of June 8, 2004*) # Indicates human disease case(s) Avian, animal or mosquito infections WA ND NH MT MN VT ME SD WI OR ID WY MI NY MA IA NE RI PA IL IN OH CT NV UT MD NJ CO WV DE KS MO VA KY DC CA OK TN NC AR AZ NM (1) SC (6) MS AL GA TX LA FL AK HI *Currently, WNV maps are updated regularly to reflect surveillance reports released by state and local health departments to the CDC Arbonet system for public distribution. Map shows the distribution of avian, animal, or mosquito infection occurring during 2004 with number of human cases if any, by state. If West Nile virus infection is reported to CDC Arbonet in any area of a state, that entire state is shaded accordingly. Data table: Indicates avian or animal infection reported to CDC ArboNET for public distribution as of June 8, 2004 from the following states: Alabama, Arizona, Arkansas, California, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, New Jersey, New York, Ohio, Oklahoma, Pennsylvania and Texas. Human cases have been reported in Arizona and New Mexico. REPORT AUTHORS Patti J. Unruh, Senior Communications Associate Shelley A. Hearne, DrPH Trust for America’s Health Executive Director Trust for America’s Health Laura M. Segal Director of Communications Allan Rosenfield, MD Trust for America’s Health Dean, Mailman School of Public Health Columbia University PEER REVIEWER Michael J. Earls Louis Sullivan, MD Communications Specialist Former Secretary, U.S. Department of Trust for America’s Health Health and Human Services 13 Endnotes 13 “CDC Watching Next for Worrisome Outbreak,” Associated Press. 1 “2003 West Nile Virus Activity in the United http://www.phillyburbs.com/pb-dyn/news/94- 05172004-301436.html 18 May 2004. States,” Centers for Disease Control and Prevention. http://www.cdc.gov/ncidod/ 14 “Fact Sheet on Rift Valley Fever,” World Health dvbid/westnile/surv&controlCaseCount03_deta Organization. http://www.who.int/mediacen- iled.htm 26 May 2004. tre/factsheets/fs207/en/ 10 June, 2004 2 “2004 West Nile Virus Activity in the United 15 “CDC Watching Next for Worrisome States, Reported as of June 22, 2004,” Centers Outbreak,” Associated Press. for Disease Control and Prevention. http://www.phillyburbs.com/pb-dyn/news/94- http://www.cdc.gov/ncidod/dvbid/west- 05172004-301436.html 18 May, 2004. nile/surv&controlCaseCount04_detailed.htm. 16 Ibid. 10 June 2004. 17 “West Nile Virus Q&A: Testing and Treating 3 “California West Nile Surveillance Information West Nile Virus in Humans,” Centers for Center,” California Department of Health Disease Control and Prevention. Services. http://www.westnile.ca.gov/ 8 June http://www.cdc.gov/ncidod/dvbid/ west- 2004. nile/qa/testing_treating.htm 26 May 2004. 4 “CDC Seeks Data on Infants Born to Women 18 “Questions About Commercial Laboratories,” with West Nile,” Center for Infectious Disease Centers for Disease Control and Prevention. and Research Policy. CIDRAP News. http://www.cdc.gov/ncidod/dvbid/westnile/q http://www.cidrap.umn.edu/cidrapcon- a/testing_treating.htm#Commercial 10 June, tent/other/wnv/news/march0304wnv.html 3 2004. March 2004. 19 Ibid 5 “Six West Nile cases in 2003 linked to donated blood,” Center for Infectious Disease and 20 Ibid Research Policy. CIDRAP News. 21 Ibid http://www.cidrap.umn.edu/cidrap/content/ 22 Core Functions and Capabilities of State Public other/wnv/news/apr0804wnv.html 8 April 2004. Health Laboratories: A White Paper for Use in 6 “Questions and Answers: Blood Transfusion, Understanding the Role and Value of Public Organ Donation, and Blood Donation Health Laboratories in Protecting our Nation’s Screening Information,” Centers for Disease Health. Washington, DC: Association of Public Control and Prevention. http://www.cdc.gov/ Health Laboratories, 2000. ncidod/dvbid/ westnile/qa/transfusion.htm 23 The CDC lab is exceeded in capabilities only 26 May 2004. by the U.S. Army Medical Research Institute 7 “Summary of West Nile Virus Activity, United of Infectious Diseases (USAMRIID). States, 2003,” from “Fifth National Conference USAMRIID is classified as a Level D labora- on West Nile Virus in the United States,” tory, the CDC is classified as Level C, and Centers for Disease Control and Prevention. state health laboratories are Level B and http://www.cdc.gov/ncidod/dvbid/westnile/co hospital and independent laboratories are nf/ppt/ 10 June 2004. designated as Level A laboratories. 8 “U.S. Poised for Epidemic West Nile Year,” 24 Witt-Kushner, J., Astles, J., et al. “Core CNN.com. http://www.cnn.com/2004/ Functions and Capabilities of State Public HEALTH/04/30/wnv.outlook 3 May, 2004. Health Laboratories: A Report of the 9 RAND Report Raises Concerns About Parts of Association of Public Health Laboratories,” California Public Health System, RAND Morbidity and Mortality Weekly Report. 2002: Corporation. http://www.rand.org/news/ 37(51):S1. press.04/06.02.html 2 June 2004. 25 Public Health Laboratories: Unprepared and 10 “U.S. Poised for Epidemic West Nile Year,” Overwhelmed. Washington, D.C.: Trust CNN.com. http://www.cnn.com/2004/ forAmerica’s Health. June 2003. HEALTH/04/30/wnv.outlook 3 May 2004. 26 “Interim Guidelines for the Evaluation of 11 Ibid. Infants Born to Mothers Infected with West Nile Virus During Pregnancy,” Centers for 12 “West Nile Battle Gets a Boost,” The Disease Control and Prevention. MMWR, 27 Coloradoan, 22 August 2003; “Worst is Over as February 2004 / 53(07): 154-157. State Tallies Up Outbreak’s Toll,” The 27 “Update: West Nile Virus Screening of Blood Coloradoan,” 7 October 2003. Donations and Transfusion-Associated Transmission — United States, 2003,” Centers for Disease Control and Prevention. MMWR, 9 April 9, 2004 / 53(13): 281-284. 14 28 “Interim Guidelines for the Evaluation of Infants Born to Mothers Infected with West Nile Virus During Pregnancy,” Centers for Disease Control and Prevention. MMWR, 27 February 2004 / 53(07): 154-157. 29 Quinlisk, Patricia MD, MPH, Medical Director and State Epidemiologist for the Iowa Department of Public Health. Statement Before the Senate Subcommittee on Labor, Health and Human Services and Education Appropriations. 3 October 2001; and Gilchrist, Mary. Director, University Hygienic Laboratory, University of Iowa and President, Association of Public Health Laboratories. Statement before the Senate Subcommittee On Labor, Health, Human Services, Education Appropriations. 3 October 2001. 30 Scutchfield, F. Douglas and Keck, C. William, Principles of Public Health Practice. Albany, New York. Delmar Publishers. 1997. 31 Public Health Laboratories: Unprepared and Overwhelmed. Washington, D.C.: Trust forAmerica’s Health. June 2003. 15