Emerging arboviral diseases in Europe The French experience Dr Marie-Claire Paty Coordinator vector born diseases surveillance Santé publique France Annual meeting for infectious disease physicians and microbiologists Karlskrona, Sweden, 19 May 2017
Arboviral diseases Viral infections transmitted by arthropods Frequently tropical Dengue Chikungunya Yellow fever Nota always tropical West Nile, Sindbis, TBE Dengue progression (Source WHO) 400 millions infections in 2010 100 million disease/ year 40-50% world population lives in areas at risk for dengue WHO and Bhatt (Nature, 2013) Expansion in the world Average annual number of Dengue cases reported to WHO and of countries reporting dengue,1955 2007 (source WHO) 2
France: mainland Europe and outermost regions Mainland France : 65 million inhabitants Mayotte : 235 132 inhabitants La Réunion: 850 996 Guadeloupe: 395 725 inhabitants Martinique: 376 847 French Guyane: 262 527 3
Factors affecting arbovirus transmission Arthropod borne viruses Interaction between virus, vector, host (people), weather, environment Virus virulence, lineage Vector competence and density International travel High number of imported cases allows local transmission where competent vector is present and conditions are favourable for mosquito virus human contact 4
Emerging arboviruses in Europe, 2017 Aedes transmitted (Aedes albopictus) Dengue, Chikungunya, Zika (incubation 2-15 days; viremia 7 days; asymptomatic cases) Culex transmitted West Nile, Sindbis Ticks TBE, CCHF Aedes albopictus One of the top 100 invasive species Bites during the day, (early morning and late afternoon ) outdoors and indoors Secondary vector or dengue chikungunya Zika, (yellow fever?) Known vector of outbreaks Dengue : Japan 1942-1944, Seychelles 1976-77, La Réunion 1977, 2004, 2012, Gabon 2007, China 2004, 2010, Hawaii 2001-02 Chikungunya : La Réunion Islands, Italy 5
A. aegypti and A. albopictus in the world Aedes aegypti CDC/ James Gathany Aedes aegypti Primary vector of dengue, chikungunya, zika, yellow fever ECDC Aedes albopictus Secondary vector of dengue, chikungunya, zika, Yellow fever? Source: Kraemer et al. Nature 2015 6
Ae. albopictus in Europe (ECDC) Originated from Asia, diffusion East to West (movement of used tyres, lucky bamboo) Continuing expansion since the 70s Introduction in Europe Albania 1979 Italy 1990 France 2004 7
Aedes albopictus in mainland France In France since 2004 (Menton town) Period of activity May November Continuous expansion Aedes albopictus, 2017 33 / 95 départements Aedes albopictus, 2009 2004 : 1st establishment 2004 Ain, Alpes-de-Haute-Provence, Alpes-Maritimes, Ardèche, Aude, Bouches-du- Rhône, Corse-du-Sud, Haute-Corse, Dordogne, Drôme, Gard, Haute- Garonne, Gironde, Hérault, Isère, Landes, Lot, Lot-et-Garonne, Pyrénées- Atlantiques, Pyrénées-Orientales, Bas-Rhin, Rhône, Saône-et-Loire, Savoie, Tarn, Tarn-et-Garonne, Var, Vaucluse, Vendée, Val-de-Marne. 8
Aedes albopictus in mainland France, municipalities 9
Repartition of Aedes in France Ae Albopictus Ae Aegypti Ae Aegypti Ae Aegypti Ae Albopictus Ae Albopictus 10
Figure 9a Arboviruses in the French territories of America Dengue endemo epidemic 2010 epidemic : 80 000 cases in Martinique + Guadeloupe (10% population) Chikungunya: 2014 emergence and epidemic October 2013 Zika: 2016 emergence and epidemic Situation épidémiologique actuelle en Guadeloupe Surveillance des cas cliniquement évocateurs u Depuis mi-décembre, le nombre hebdomadaire moyen de cas cliniquement évocateur reçus par les médecins généraliste en consultation est estimé à sept pour l ensemble de la G adeloupe (Figure 8). Il n est pas observé de reprise de la circulation virale depuis la fin de l épidémie en semaine 2014-47. 160 000 cases in Martinique + Figure 8 Nombre hebdomadaire cas cliniquement évocateurs de chikungunya, vus en médecine Guadeloupe ville, estimé à partir des données du réseau (20% de médecins sentinelles population) - S2013-52 à S2015-02 Guadeloupe 6500 6000 5500 5000 May 2015 4500 4000 3500 3000 2500 2000 1500 1000 500 0 Surveillance des passages aux urgences Dengue epidemiologic curve and serotypes, Martinique 2006-2016 Chikungunya epidemic curve, Guadeloupe W52 2013 à W 02 2015 Au CHU de Pointe à Pitre, le nombre hebdomadaire de passages aux urgences pour chikungunya était compris entre zéro et trois au cours des semaines 2014-51 à 2015-02 (Figure 9a). Au CH de Basse-Terre, ce nombre était inférieur ou égal à un (Figure 9b) 11
Arboviruses in mainland France Conditions for local transmission are met: Imported cases in travellers Ae albopictus established and active Preparedness and control plan (since 2006)- 5 levels Epidemiological surveillance Notification Enhanced surveillance in the departments where Ae albopictus is established and active (May November) Vector control (larvicide and adulticide when appropriate) Around every viremic case Airports, hospitals Information and awareness Blood safety 12
Dengue in travellers, France Dengue cases notification Country of acquisition Epidemic French Caribbean 2016 => Vector control where Ae albopictus established and active (May November) 2015 13
Autochthonous dengue transmission in mainland France 6 episodes: 2010, 2013, 2014, 2015 Mainly August September 1 to 7 cases Primary case not always identified: 2010: French Caribbean* Aix, Oct 2013 1 case (DENV 2) Nice, Sept 2010 2 cases (DENV 1) 2013:? 2014: Thailand and? and? 2015: French Polynesia *La Ruche et al. First two autochthonous dengue virus infections in metropolitan France, September 2010. Euro Surveill. 2010 Nîmes, Aug- Sept 2015 7 cases Aubagne, Aug Sept 2014 2 cases (DENV 2) Toulon Aug 2014 1 case (DENV 1) Toulon Sept 2014 1 case (DENV 2) 14
Dengue outbreak Nîmes August September 2015 First 2 cases identified 14 Aug: DENV 1 Epidemiological investigation 7 dengue cases locally acquired August 8(3 cases), 12, 13, 18 and Sept 11 Within 300m diameter area Primary case: imported from French Polynesia, symptom onset 4 July Vector control Elimination of breeding sites Ultra-low-volume spraying of deltamethrin Autochthonous dengue outbreak in Nîmes, South of France, July to September 2015. - Succo et al. Euro Surveill. 2016 15
Croatia, Dengue outbreak 2010 Aedes albopictus : Established since 2004 (Zagreb), disseminated to Adriatic coast in 2006 Sept 2010: DENV infection in a German traveller returning from Croatia Epidemiological investigation in Croatia Active case finding : 2 additional cases in the same village Serum survey Oct-2010 : 12 recent infections (IgM +) Schmidt-Chanasit, Eurosurveillance 2010 16
Dengue transmission in Europe France 2010 France 2013 France 2014 France 2015 Croatia 2010 Madeira 2012-2013 >2000 cases, Ae aegypti 17
Chikungunya: La Réunion 2005-2006 1/3 population affected: 250 000 cases over 775 000 inhabitants Vector : Ae albopictus Virus ECSA lineage- E1-226V variant, more efficiently transmitted by A.albopictus 18
Chikungunya WHO, 2008 WHO, 2014 WHO, 2016 October 2013 Vector Ae Aegypti Virus Asian lineage 19
Chikungunya in travellers Country of acquisition Epidemic French Caribbean, 2014 2014 2015 => Vector control where Ae albopictus established and active (May November) 2016 20
Chikungunya outbreak - Montpellier, Sept- Oct 2014 First case identified 1 Oct 2014 Epidemiological investigation 12 chikungunya cases locally acquired 8 September to 22 October 2014 Within 300m diameter area Primary case: imported from Cameroon, symptom onset 30 August ECSA lineage, E1-226V variant Traitement LAV le 19/10 Traitement LAV le 23/10 Traitement LAV le 24/10 Traitement LAV le 30/10 Cas de chikungunya importé Cas de chikungunya autochtone Foyer autochtone familial (4 cas) 11/10 Date de début des signes Enquête en porte à porte les 22 et 23/10 Boîtage le 29/10 30/10/2014 Vector control Elimination of breeding sites Ultra-low-volume spraying of deltamethrin 11/10 22/10 20/09 18/09 24/09 09/10 09/09 12/10 14/09 31/08 16/09 Chikungunya outbreak in Montpellier, France, September to October 2014. Delisle et al. Euro Surveill. 2015 21
Chikungunya transmission in Europe France 2010: 2 cases (ECSA -India). End August France 2014: 12 cases (ECSA -Cameroon) Italy 2007: 300 cases (ECSA- India) Grandadam et al. Chikungunya Virus, Southeastern France. Emerg Infect Dis. 2011 Rezza et al. Infection with chikungunya virus in Italy: an outbreak in a temperate region. Lancet 2007 22
Zika virus French Caribbean and Guyana January 2016 23
Zika in French Caribbean, 2016 Martinique Epidemic January October 2016 Guadeloupe Epidemic April November 2016 35190 clinical cases 28345 clinical cases 732 infected pregnant women 753 infected pregnant women 24 birth defects 18 birth defects March June End epidemic End epidemic 24
Zika in mainland France, 01/01 to 30/01/2017 1120 cases in travellers 82 % returning from French Caribbean 5 neurological complications 62 pregnant women 12 autochthonous cases through sexual transmission* Zika Country of acquisition, 2016 No vector transmission * Evidence of Sexual Transmission of Zika Virus. D Ortenzio et al. N Engl J Med 2016 25
Zika in Europe (Source ECDC) From June 2015 to 27 January 2017 21 countries have reported 2 081 travel-associated Zika virus infections (Austria, Belgium, the Czech Republic, Denmark, Finland, France, Greece, Hungary, Ireland, Italy, Luxembourg, Malta, the Netherlands, Norway, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden and the United Kingdom) 9EU/EEA Member States have reported 103 Zika cases among pregnant women. 26
Prevention and control Awareness and information Health professionals Travellers Citizens Municipalities Vector control Around viremic imported cases Airports, hospitals 27
Blood safety issues Dengue, chikungunya, Zika Deferral of donors 28 days after returning from affected areas at risk In case of outbreak or epidemic: stop donation or screening Zika Assessment of the risk of blood donations in metropolitan France from donors infected after sexual contamination, linked to travelers returning from an affected areas low but deferral of donors with sexual partner returning from Zika area since less than 3 months 28
Conclusion Expansion of classically tropical arboviruses to temperate areas of Europe related to Expansion of vector Aedes albopictus in Europe Worldwide expansion of these viruses Globalisation, travels, migrations Not only the case of Aedes transmitted arboviruses Shistosomiasis in Corsica (Cavu River, 2013 2015) Crimea Congo: 2 cases in Spain (2016) Possible diagnoses for patients who didn t travel outside Europe 29
Thank You for your attention Acknowledgments to Santé publique France team in Paris and regions Reference laboratory for arboviruses Entomologists Clinicians and biologists 30