Increased recognition of Powassan encephalitis in the United States, 1999-2005.

Powassan virus (POWV) disease is a rare human disease caused by a tick-borne encephalitis group flavivirus maintained in a transmission cycle between Ixodes cookei and other ixodid ticks and small and medium-sized mammals. During 1958-1998, only 27 POWV disease cases (mostly Powassan encephalitis) were reported from eastern Canada and the northeastern United States (average, 0.7 cases per year). During 1999-2005, nine cases (described herein) of serologically confirmed POWV disease were reported in the United States (average, 1.3 cases per year): four from Maine, two from New York, and one each from Michigan, Vermont, and Wisconsin. The Michigan and Wisconsin cases are the first ever reported from the north-central United States. Of these nine patients, 5 (56%) were men, the median age was 69 years (range: 25-91 years), and 6 (67%) had onset during May-July. All but one patient developed encephalitis with acute onset of profound muscle weakness, confusion, and other severe neurologic signs. In one case, no neurologic symptoms were present but the presence of pleocytosis, an elevated cerebrospinal fluid (CSF) protein concentration, and POWV-specific immunoglobulin M in CSF suggested neuroinvasion. All patients recovered from their acute disease, but most had long-term neurologic sequelae. Periresidential ecologic investigations were performed in three cases, including tests of local mammals and ticks for evidence of POWV infection. Woodchucks (Marmota monax), striped skunks (Mephitis mephitis), and a raccoon (Procyon lotor) collected at two of the Maine case-patients' residences had neutralizing antibody titers to POWV. I. cookei were found on woodchucks and skunks and questing in grassy areas of one of these residences; all were negative for POWV. Although POWV disease is rare, it is probably under-recognized, and it causes significant morbidity, and thus is an additional tick-borne emerging infectious disease entity. Because no vaccine or specific therapy is available, the basis of prevention is personal protection from ticks (or "tick hygiene") and reduced exposure to peridomestic wild mammals.

Risk factors for infection during a dengue-1 outbreak in Maui, Hawaii, 2001.

Autochthonous dengue virus transmission, last identified in the state of Hawaii in 1945, was detected again in 2001. A seroepidemiological survey in a high-incidence community (Nahiku) and a nearby low-incidence community (Hana Subdivision) was implemented. The two communities studied differed in median household size (two vs. four persons), median lot size (2.8 vs. 0.8acres), proportion of households with mosquito larvae (81 vs. 28%) and incidence of recent infection (39% [28/72] vs. 1% [1/131]). The average number of reported anti-mosquito actions by residents of both locations remained low, and approximately 50% (42/80) of the inspected houses had larvae, evidencing the need for more effective community mosquito control. Logistic regression analysis of risk factors for infection in Nahiku identified residing in properties with birds in the house or yard as significantly associated with infection (odds ratio 7.0, 95% CI 1.7-28.5), probably as an indicator of unspecified environmental characteristics that were attractive to the vector. We documented that nearly 40% of Nahiku residents had acquired dengue locally in 2001 and that undetected dengue outbreaks had occurred in Hawaii. Our data suggest that ecological characteristics may help Hawaii health officials identify communities at increased risk of dengue infection.

Early season crow mortality as a sentinel for West Nile virus disease in humans, northeastern United States.

The 1999 New York epidemic of human West Nile virus (WN) encephalitis and meningitis was preceded by a crow die-off also caused by WN infection. As one component of the subsequently developed national surveillance system, crow mortality data were collected to detect WN activity before humans might become infected. However, predicting areas at risk for human WN disease likely requires assessment of multiple factors, including the intensity and timing of crow epizootics. To identify early season measures of WN activity in crows associated with subsequent WN disease in humans, county-level crow mortality data from seven northeastern states were analyzed. A predictive model was developed based on analysis of 2000 surveillance data and then assessed for 2001. To characterize the intensity of early season WN activity in crows, 15 variables were constructed from surveillance data of 52 counties that tested at least four crows during the early season (defined as June 17-July 28, 2000). County values for each variable were dichotomized at the 75th percentile into "high" and "low" activity. Multivariate analysis indicated that "high" early season activity of two variables-density of reported dead crow sightings (reported dead crows/area) and [(WN-infected crows/tested crows) x (human population)]--were associated with report of at least one human WN disease case (for each variable: adjusted odds ratio, 6.9; 95% confidence interval, 1.2-40.6). An assessment of this model using 2001 surveillance data from 61 counties yielded similar findings. With emphasis on early season WN activity, crow surveillance may allow timely targeting of interventions to protect the public health.