Non-imported malaria in Italy: paradigmatic approaches and public health implications following an unusual cluster of cases in 2017.

BACKGROUND: The European region achieved interruption of malaria transmission during the 1970s. Since then, malaria control programs were replaced by surveillance systems in order to prevent possible re-emergence of this disease. Sporadic cases of non-imported malaria were recorded in several European countries in the past decade and locally transmitted outbreaks of Plasmodium vivax, most probably supported by Anopheles sacharovi, have been repeatedly reported from Greece since 2009. The possibility of locally-transmitted malaria has been extensively studied in Italy where the former malaria vector An. labranchiae survived the control campaign which led to malaria elimination. In this study, we present paradigmatic cases that occurred during a 2017 unusual cluster, which caused strong concern in public opinion and were carefully investigated after the implementation of the updated malaria surveillance system. METHODS: For suspected locally-transmitted malaria cases, alerts to Ministry of Health (MoH) and the National Institute of Health (ISS) were mandated by the Local Health Services (LHS). Epidemiological investigations on the transmission modes and the identification of possible infection's source were carried out by LHS, MoH and ISS. Entomological investigations were implemented locally for all suspected locally-transmitted cases that occurred in periods suitable to anopheline activity. Molecular diagnosis by nested-PCR for the five human Plasmodium species was performed to support microscopic diagnosis. In addition, genotyping of P. falciparum isolate was carried out to investigate putative sources of infection and transmission modalities. RESULTS: In 2017, a cluster of seven non-imported cases was recorded from August through October. Among them, P. ovale curtisi was responsible of one case whereas six cases were caused by P. falciparum. Two cases were proved to be nosocomial while the other five were recorded as cryptic at the end of epidemiological investigations. CONCLUSIONS: The epidemiological evidence shows that the locally acquired events are sporadic, often remain unresolved and classified as cryptic ones despite investigative efforts. The "cluster" of seven non-imported cases that occurred in 2017 in different regions of Italy therefore represents a conscious alert that should lead us to maintain a constant level of surveillance in a former malaria endemic country.

Secondary Autochthonous Outbreak of Chikungunya, Southern Italy, 2017.

In 2017, a chikungunya outbreak in central Italy later evolved into a secondary cluster in southern Italy, providing evidence of disease emergence in new areas. Officials have taken action to raise awareness among clinicians and the general population, increase timely case detection, reduce mosquito breeding sites, and promote mosquito bite prevention.

Vector competence of Aedes albopictus for the Indian Ocean lineage (IOL) chikungunya viruses of the 2007 and 2017 outbreaks in Italy: a comparison between strains with and without the E1:A226V mutation.

We compared the vector competence of an Italian population of Aedes albopictus for two strains of chikungunya virus (CHIKV), with and without E1:A226V mutation, responsible for outbreaks in 2007 in the Emilia Romagna region and 2017 in the Lazio and Calabria regions, respectively. Ae. albopictus showed similar vector competence for both viral strains indicating that E1:A226V mutation is not exclusively responsible for ability of CHIKV to replicate well in this mosquito species.

Cryptic severe Plasmodium falciparum malaria in a Moroccan man living in Tuscany, Italy, August 2018.

In August 2018 a Moroccan man living in Tuscany developed Plasmodium falciparum malaria. The patient declared having not recently visited any endemic country, leading to diagnostic delay and severe malaria. As susceptibility to P. falciparum of Anopheles species in Tuscany is very low, and other risk factors for acquiring malaria could not be completely excluded, the case remains cryptic, similar to other P. falciparum malaria cases previously reported in African individuals living in Apulia in 2017.

Detection of a chikungunya outbreak in Central Italy, August to September 2017.

An autochthonous chikungunya outbreak is ongoing near Anzio, a coastal town in the province of Rome. The virus isolated from one patient and mosquitoes lacks the A226V mutation and belongs to an East Central South African strain. As of 20 September, 86 cases are laboratory-confirmed. The outbreak proximity to the capital, its late summer occurrence, and diagnostic delays, are favouring transmission. Vector control, enhanced surveillance and restricted blood donations are being implemented in affected areas.

Experimental studies of susceptibility of Italian Aedes albopictus to Zika virus.

We report a study on vector competence of an Italian population of Aedes albopictus for Zika virus (ZIKV). Ae. albopictus was susceptible to ZIKV infection (infection rate: 10%), and the virus could disseminate and was secreted in the mosquito's saliva (dissemination rate: 29%; transmission rate: 29%) after an extrinsic incubation period of 11 days. The observed vector competence was lower than that of an Ae. aegypti colony tested in parallel.

Genetic and phenotypic variation of the malaria vector Anopheles atroparvus in southern Europe.

BACKGROUND: There is a growing concern that global climate change will affect the potential for pathogen transmission by insect species that are vectors of human diseases. One of these species is the former European malaria vector, Anopheles atroparvus. Levels of population differentiation of An. atroparvus from southern Europe were characterized as a first attempt to elucidate patterns of population structure of this former malaria vector. Results are discussed in light of a hypothetical situation of re-establishment of malaria transmission. METHODS: Genetic and phenotypic variation was analysed in nine mosquito samples collected from five European countries, using eight microsatellite loci and geometric morphometrics on 21 wing landmarks. RESULTS: Levels of genetic diversity were comparable to those reported for tropical malaria vectors. Low levels of genetic (0.004

Larvicidal activity of Ocimum campechianum, Ocotea quixos and Piper aduncum essential oils against Aedes aegypti.

Aedes aegypti, the main arbovirus vector of the Yellow fever, Dengue, Chikungunya and Zika viruses, is widely distributed in tropical and subtropical areas throughout the world. Preventive control efforts have been implemented worldwide aimed at reducing its impact on human health. The recent reduction of chemicals available for vector control due to their negative impact on the environment and human health and the increase in mosquito resistance to insecticides have driven the research community to identify and evaluate sustainable alternatives to synthetic insecticides. In this study, the potential larvicidal effect of essential oils extracted from Ocimum campechianum, Ocotea quixos and Piper aduncum were tested in vitro. GC and GC-MS analyses showed that the main compounds were eugenol (18%), 1,8-cineole (39%) and dillapiole (48%), respectively. Susceptibility to essential oils was measured according to the WHO protocol. After 24 h, the mean percentage mortality ranged from 2.7 to 100% for P. aduncum, from 2.2 to 100% for O. campechianum, and from 2.9 to 100% for O. quixos. The highest potential was displayed by P. aduncum, followed by O. campechianum and O. quixos, with LC50 values of 25.7, 69.3 and 75.5 ppm, respectively. The rapid and effective larvicidal activity of these three oils led us to consider these results to be promising, also considering the possibility of local cultivation of these plants in tropical and subtropical areas and the simple technology for their large-scale preparation and production. Further studies are needed to evaluate the individual components and their activity as larvicides.

Vector competence of Italian Aedes albopictus populations for the chikungunya virus (E1-226V).

BACKGROUND: Chikungunya virus (CHIKV) is an emerging arbovirus, belonging to the Togaviridae family, Alphavirus genus, transmitted by Aedes spp. mosquitoes. Since 2007, two different CHIKV strains (E1-226A and E1-226V) have been responsible for outbreaks in European countries, including Italy, sustained by Ae. albopictus mosquitoes. FINDINGS: In this study, we assessed the susceptibility to the CHIKV E1-226V, strain responsible for the Italian 2007 outbreak, of eight Ae. albopictus populations collected in Northern, Central, Southern, and Island Italy, by experimental infections. Vector competence was evaluated by estimating infection, dissemination, and transmission rates (IR, DR, TR), through detection of the virus in the bodies, legs plus wings, and saliva, respectively. Additionally, vertical transmission was evaluated by the detection of the virus in the offspring. The results of our study demonstrated that the Italian populations of Ae. albopictus tested were susceptible to CHIKV infection, and can disseminate the virus outside the midgut barrier with high values of IR and DR. Viral infectious RNA was detected in the saliva of three populations from Central, Southern, and Island Italy, also tested for TR and population transmission rate (PTR) values. No progeny of the first and second gonotrophic cycle were positive for CHIKV. CONCLUSIONS: This study strongly confirms the role of Ae. albopictus as a potential CHIKV vector in Italy. This may represent a threat, especially considering both the high density of this species, which is widespread throughout the country, and the increasing number of cases of imported arboviruses.

Molecular identification of Palearctic members of Anopheles maculipennis in northern Iran.

BACKGROUND: Members of Anopheles maculipennis complex are effective malaria vectors in Europe and the Caspian Sea region in northern Iran, where malaria has been re-introduced since 1994. The current study has been designed in order to provide further evidence on the status of species composition and to identify more accurately the members of the maculipennis complex in northern Iran. METHODS: The second internal transcribed spacer of ribosomal DNA (rDNA-ITS2) was sequenced in 28 out of 235 specimens that were collected in the five provinces of East Azerbayjan, Ardebil, Guilan, Mazandaran and Khorassan in Iran. RESULTS: The length of the ITS2 ranged from 283 to 302 bp with a GC content of 49.33-54.76%. No intra-specific variations were observed. Construction of phylogenetic tree based on the ITS2 sequence revealed that the six Iranian members of the maculipennis complex could be easily clustered into three groups: the An. atroparvus-Anopheles labranchiae group; the paraphyletic group of An. maculipennis, An. messeae, An. persiensis; and An. sacharovi as the third group. CONCLUSION: Detection of three species of the An. maculipennis complex including An. atroparvus, An. messae and An. labranchiae, as shown as new records in northern Iran, is somehow alarming. A better understanding of the epidemiology of malaria on both sides of the Caspian Sea may be provided by applying the molecular techniques to the correct identification of species complexes, to the detection of Plasmodium composition in Anopheles vectors and to the status of insecticide resistance by looking to related genes.

Preliminary study on 2 colour patterns in Ochlerotatus caspius (Pallas, 1771) (Diptera, Culicidae).

Ochlerotatus caspius is a mosquito of medical and veterinary relevance both for its synanthropy and for its potential role in transmission of viruses and nematodes in the areas that it inhabits. Due to its wide range and the marked variability in the adult colour pattern, some authors have recognized Ochlerotatus caspius as a complex of species. In this study, we purposed to evaluate the possible taxonomic heterogeneity between 2 chromatic forms by using both morphological and molecular approaches. The preliminary results based on the identity of the rRNA internal transcribed spacer 2 (ITS-2) lead us to believe the 2 forms as a single species with a chromatic polymorphism.

Finding of Anopheles (Anopheles) hyrcanus (Pallas, 1771) (Diptera, Culicidae) during the entomological surveillance for West Nile virus in Umbria, Italy.

This study reports the mosquito collections conducted in July-August 2013 in Castiglione del Lago (Umbria Region, Italy) during the entomological surveillance within the West Nile national control program. The mosquito collections showed the noteworthy occurrence of Anopheles hyrcanus s.l. (n = 156; 35.8% of the whole sample), a relatively rare mosquito species in Italy, with molecular analyses con rming that these mosquitoes belong to An. hyrcanus s.s. The same catching site was characterized by a relevant richness in mosquito species, in particular the following were found: Anopheles maculipennis s.l. (n = 146; 33.5% composed by 80% Anopheles melanoon, 13.3% Anopheles maculipennis s.s. and 6.7% Anopheles atroparvus), Culex pipiens s.l. (n = 116; 26.6% composed by 90% Cx. p. pipiens, 5% Cx. p. molestus and 5% Cx. p. pipiens/molestus), Culiseta annulata (n = 10; 2.3%), Aedes albopictus (n = 3; 0.7%), and Anopheles claviger (n = 5; 100%).

First record of the invasive mosquito species Aedes (Stegomyia) albopictus (Diptera: Culicidae) on the southernmost Mediterranean islands of Italy and Europe.

BACKGROUND: Aedes albopictus, a known worldwide vector of several mosquito-borne disease pathogens including dengue, chikungunya and Zika viruses, was introduced into Europe in the late 1970s through global trade. First recorded in northern Italy in 1990, this mosquito species has rapidly spread throughout the country, where it was responsible for an outbreak of chikungunya in 2007 that affected more than 200 people. As part of the VectorNet project, which is aimed at improving preparedness and responsiveness for animal and human vector-borne diseases in Europe, a mosquito targeted study was carried out on the three southernmost Italian islands. The objective was to verify the current European southern distribution limits of Ae. albopictus and the potential occurrence of other invasive mosquito species, in the light of the introduction of high risk for vector-borne disease pathogens into Europe via migration flows. RESULTS: In the summer 2015, six surveys for container-breeding mosquitoes were carried out by setting up a network of oviposition traps and BG Sentinel traps in selected areas on the islands of Pantelleria, Lampedusa and Linosa. Aedes albopictus was found on all three islands under investigation. The consequences on public health with regard to the presence of this mosquito vector and the migrant people entering the country from Africa and the Middle East are also discussed here. CONCLUSIONS: The detection of the Asian tiger mosquito on these islands, which represent the last European strip of land facing Africa, has important implications for public health policy and should prompt the national authorities to implement tailored surveillance activities and reinforce plans for preparedness strategies in such contexts.

Cold acclimation and overwintering of female Aedes albopictus in Roma.

Eight years after the introduction and establishment of Aedes albopictus in Roma, females of the species extended their trophic activity to the coldest months of the year. Winter monitoring carried out from December 2003 to March 2004 in the urban area of the capital city of Italy recorded a weekly rate of positive ovitraps constantly around 30%, for the entire period of surveillance (14 wk). Eggs from ovitraps did not hatch when stimulated in laboratory with a wet and dry procedure. The hypothesis that long-lived female Ae. albopictus, belonging to the last seasonal generation, could have continued their trophic activity for 3 months, or that 1 or more cycles of reproduction have occurred in peculiar breeding sites, where a favorable microclimate may have allowed the development of at least 1 larval generation, are discussed and compared with the existing literature.

Ecological Distribution and CQ11 Genetic Structure of Culex pipiens Complex (Diptera: Culicidae) in Italy.

Mosquitoes in the Culex pipiens complex are considered to be involved in the transmission of a range of pathogens, including West Nile virus (WNV). Although its taxonomic status is still debated, the complex includes species, both globally distributed or with a more limited distribution, morphologically similar and characterised by different physiological and behavioural traits, which affect their ability as vectors. In many European countries, Cx. pipiens and its sibling species Culex torrentium occur in sympatry, exhibiting similar bionomic and morphological characters, but only Cx. pipiens appears to play a vector role in WNV transmission. This species consists of two biotypes, pipiens and molestus, which can interbreed when in sympatry, and their hybrids can act as WNV-bridge vectors, due to intermediate ecological features. Considering the yearly WNV outbreaks since 2008 and given the morphological difficulties in recognising species and biotypes, our aim was to molecularly identify and characterised Cx. pipiens and Cx. torrentium in Italy, using recently developed molecular assays. Culex torrentium was not detected; as in other European countries, the pipiens and molestus biotypes were widely found in sympatry with hybrids in most environments. The UPGMA cluster analysis applied to CQ11 genotypic frequencies mainly revealed two groups of Cx. pipiens populations that differed in ecological features. The high propensity of the molestus biotype to exist in hypogean environments, where the habitat's physical characteristics hinder and preclude the gene flow, was shown. These results confirmed the CQ11 assay as a reliable diagnostic method, consistent with the ecological and physiological aspects of the populations analysed. Since the assessment of the actual role of three biotypes in the WNV circulation remains a crucial point to be elucidated, this extensive molecular screening of Cx. pipiens populations can provide new insights into the ecology of the species and may give useful indications to plan and implement WNV surveillance activities in Italy.

Bioengineering of a cellulosic fabric for insecticide delivery via grafted cyclodextrin.

beta-Cyclodextrin (beta-CD) can be easily grafted onto cellulosic textiles through covalent bonds. In such a way beta-CD empty cavities provide an efficient tool for entrapping different kinds of hydrophobic molecules on the surface of the fabric and releasing them slowly in time. The capability of cyclodextrins to include hydrophobic molecules such as fragrances, antimicrobial agents, and other chemicals can be then exploited to produce new grafted textiles with peculiar and useful performances. In this work we report the inclusion of two different products, the pyrethroid insecticide permethrin (PERM) and the insect repellent N,N-diethyl-m-toluamide (DEET), into beta-CD molecules grafted on cotton fabric. UV-vis spectrophotometry and thermal analysis confirmed the presence of the guest molecules on the fabric surface. Bioassays were carried out on two mosquito species of medical importance, Aedes aegypti and Anopheles stephensi; knock down effect and mortality were measured using standard World Health Organization (WHO) cone tests. Repellency and irritancy (blood feeding inhibition) were also measured using cage tests and a baited tunnel device. PERM-treated fabrics kept the insecticidal/irritant efficacy even for a long time after the treatment, whereas DEET activity lasted more shortly.

Oviposition substrate in Asian tiger mosquito surveillance: Do the sizes matter?

Ovitraps are regarded as a reliable system to monitor Aedes albopictus dynamics. However, the dimensions of the oviposition substrate are not standardized, and no studies have investigated which should be the most effective sizes. In this study, the effect of paddle sizes in tiger mosquito egg collection was evaluated. Egg count and density on the wide surfaces and margins of different-sized oviposition substrates have been evaluated in two studies (A and B). In study A, a total of 29,995 Ae. albopictus eggs was counted in 250 classic oviposition substrates. Eggs were found on both wide surfaces (53.1%) and margins (46.9%). Egg density was significantly larger in margins compared to wide surfaces. Overall in study B, 983 Ae. albopictus eggs were collected. According to paddle sizes, 51.8% of eggs were on large and 48.2% on small paddles. Mean egg density of wide surfaces was significantly larger in small paddles (0.25 eggs/cm(2) ) compared to large paddles (0.06 eggs/cm(2) ). Results indicate that wider oviposition substrates do not mean larger number of Ae. albopictus eggs. Indeed, on paddles four times thinner than others, the number of eggs counted was not statistically different. These findings suggest that small paddles may be routinely employed in ovitraps, thus allowing savings of materials and money.

Efficacy of Two Common Methods of Application of Residual Insecticide for Controlling the Asian Tiger Mosquito, Aedes albopictus (Skuse), in Urban Areas.

After its first introduction in the 1980's the Asian tiger mosquito, Aedes albopictus (Skuse), has spread throughout Southern Europe. Ae. albopictus is considered an epidemiologically important vector for the transmission of many viral pathogens such as the yellow fever virus, dengue fever and Chikungunya fever, as well as several filarial nematodes such as Dirofilaria immitis or D. repens. It is therefore crucial to develop measures to reduce the risks of disease transmission by controlling the vector populations. The aim of the study was to compare the efficacy of two application techniques (mist vs. stretcher sprayer) and two insecticides (Etox based on the nonester pyrethroid Etofenprox vs. Microsin based on the pyrethroid type II Cypermetrin) in controlling adult tiger mosquito populations in highly populated areas. To test the effect of the two treatments pre- and post-treatment human landing rate counts were conducted for two years. After one day from the treatment we observed a 100% population decrease in mosquito abundance with both application methods and both insecticides. However, seven and 14 days after the application the stretcher sprayer showed larger population reductions than the mist sprayer. No effect of insecticide type after one day and 14 days was found, while Etox caused slightly higher population reduction than Microsin after seven days. Emergency measures to locally reduce the vector populations should adopt adulticide treatments using stretcher sprayers. However, more research is still needed to evaluate the potential negative effects of adulticide applications on non-target organisms.