Infection with chikungunya virus in Italy: an outbreak in a temperate region.

BACKGROUND: Chikungunya virus (CHIKV), which is transmitted by Aedes spp mosquitoes, has recently caused several outbreaks on islands in the Indian Ocean and on the Indian subcontinent. We report on an outbreak in Italy. METHODS: After reports of a large number of cases of febrile illness of unknown origin in two contiguous villages in northeastern Italy, an outbreak investigation was done to identify the primary source of infection and modes of transmission. An active surveillance system was also implemented. The clinical case definition was presentation with fever and joint pain. Blood samples were gathered and analysed by PCR and serological assays to identify the causal agent. Locally captured mosquitoes were also tested by PCR. Phylogenetic analysis of the CHIKV E1 region was done. FINDINGS: Analysis of samples from human beings and from mosquitoes showed that the outbreak was caused by CHIKV. We identified 205 cases of infection with CHIKV between July 4 and Sept 27, 2007. The presumed index case was a man from India who developed symptoms while visiting relatives in one of the villages. Phylogenetic analysis showed a high similarity between the strains found in Italy and those identified during an earlier outbreak on islands in the Indian Ocean. The disease was fairly mild in nearly all cases, with only one reported death. INTERPRETATION: This outbreak of CHIKV disease in a non-tropical area was to some extent unexpected and emphasises the need for preparedness and response to emerging infectious threats in the era of globalisation.

An overview of the lesson learned in almost 20 years of fight against the "tiger" mosquito.

Since its introduction in Italy in 1990, Aedes albopictus has spread quickly across the country, being at present reported in scattered foci in all regions below 600 m of altitude. The most important items of the lesson learned in almost 20 years of fight against the "Tiger" in Italy are here reported and discussed.

Age-related prevalence of Plasmodium falciparum circumsporozoite antibody in an hyperendemic area of Madagascar, and its relationship with parasite prevalence.

An epidemiologic survey on malaria endemicity levels, including entomologic, parasitologic, and immunologic indicators, was carried out in a village of the Madagascar highlands (Analaroa) at the end of the 1990-1991 rainy season. The results indicate that malaria is hyperendemic and Anopheles funestus is the main vector in the area. The prevalence of parasitemia decreased with age from a maximum level of about 60% in children less than five years of age to a minimum of about 16% among those more than 29 years of age. The prevalence of Plasmodium falciparum circumsporozoite antibodies (Ab-Cs) increased with age from a minimum level of about 10% in children less than five years of age to a maximum of 71.7% among those more than 29 years of age. An inverse correlation was observed between P. falciparum prevalence and levels of Ab-Cs and parasite prevalence. The study confirmed that prevalence and Ab-Cs levels are reliable indicators of malaria endemicity in hyperendemic areas. Schoolchildren between five and 14 years of age are considered the most practical and susceptible group for this kind of epidemiologic study.

Plasmodium falciparum circumsporozoite antibody prevalence in Madagascar: a longitudinal study in three different epidemiologic areas.

A longitudinal study on the prevalence of Plasmodium falciparum circumsporozoite antibodies (Ab-CS) was carried out in 15 villages of three epidemiologic areas of Madagascar: the highlands, east coast, and the southwest region. A total of 3,967 blood samples were collected from November 1989 to April 1991 from cohorts of resident schoolchildren. The prevalence of Ab-CS in the examined population varied greatly according to the different ecoepidemiologic areas of the country. A correlation analysis was made between Ab-CS and P. falciparum parasite prevalence in the same population. High Ab-CS prevalence rates (25-75%) and levels (optical density = 0.28-0.76) were observed in the villages of the east coast (mesoendemic stable malaria). The Ab-CS prevalence rates varied from 0 to 37% in the highlands and southwest region villages (unstable malaria). The use of Ab-CS prevalence is proposed to be a useful and reliable seroepidemiologic marker of malaria endemicity in those areas of Madagascar in which malaria transmission is high and continues for more than four months a year.

Impact of the malaria control campaign (1993-1998) in the highlands of Madagascar: parasitological and entomological data.

Malaria transmission in the central highlands of Madagascar was interrupted in the 1960s by a national control program that used DDT indoor spraying and mass treatment with chloroquine. At the end of the 1980s in this region, epidemic malaria reappeared. Italian health authorities provided technical assistance to the National Malaria Control Program since the beginning of the resurgence of malaria in the central highlands. Yearly residual house spraying performed for 5 years (1993-1998) and the availability of antimalarial drugs reduced malaria transmission to very low levels, with improvement in parasitologic and entomologic indexes. A significant reduction of malaria prevalence was observed in the villages located at altitudes of 1,000-1,500 m, corresponding to the stratum of unstable malaria that was the main target of the antivector interventions. A significant reduction of malaria prevalence was also observed in the villages located at altitudes of 900-1,000 m, where malaria transmission is stable. The main vector Anopheles funestus was dramatically reduced in abundance and distribution in the sprayed areas.

Avermectins, MK-933 and MK-936, for mosquito control.

Two avermectins were shown to be effective as mosquito larvicides or when fed to adult female mosquitoes in sucrose solution or in blood. Larval LC50 values of compounds MK-933 and MK-936, expressed as parts per billion, were found to be 3.94 and 2.42 for Culex pipiens, 5.85 and 2.90 for Anopheles stephensi and 23.4 and 10.4 for Aedes aegypti. When fed to adult females of An. stephensi, Ae. aegypti or Cx quinquefasciatus, MK-933 at 2.8mg active ingredient per litre in sucrose solution caused complete mortality within 60 hours. When female mosquitos engorged blood from mice injected subcutaneously 12 hours previously with MK-933 at 82 mg a.i./kg, mortality rates after 36 hours were 100% for An. stephensi, over 60% for Ae. aegypti and over 50% for Cx quinquefasciatus. Thus the systemic insecticidal effect was greater against anopheline than against culicine female mosquitoes.

Prevention and morbidity of malaria in non-immune subjects; a case-control study among Italian troops in Somalia and Mozambique, 1992-1994.

The impact of malaria on Italian troops taking part in 1992-1994 in the United Nations Organization humanitarian missions in Somalia and Mozambique is discussed. In Somalia, 18 cases of Plasmodium falciparum malaria occurred among 11,600 soldiers; the overall attack rate was 0.4 cases/1000/month of exposure and the risk of malaria was effectively reduced by chemoprophylaxis with chloroquine plus proguanil (C+P) (odds ratio [OR] = 0.05, 95% confidence limits [95% CL] 0.02-0.16). In Mozambique, 119 cases of P.falciparum malaria occurred among 4800 soldiers; most cases (100) occurred in the first months of deployment (late March-June 1993), with an attack rate of 17 cases/1000/month, when C+P was the recommended chemoprophylactic regimen; the remaining 19 cases occurred subsequently, with an attack rate of 1.8 cases/1000/month, after C+P was replaced by mefloquine in July 1993. Protection achieved by C+P was unsatisfactory (OR = 0.37, 95% CL 0.21-0.67), while chemoprophylaxis with mefloquine effectively reduced the risk of malaria in Mozambique (OR = 0.03; 95% CL 0.01-0.10). A significant number of malaria infections was also detected among soldiers following their return home from Somalia (147 cases) and Mozambique (40 cases); these were due mainly to P. vivax. Fifteen of 113 P. vivax primary infections imported from Somalia (13.3%) relapsed 2-13 months after the primary attack. Because of the small proportion of relapsing P. vivax tropical strains, primaquine may be limited to radical treatment of relapses or, more extensively, of all P. vivax infections, but it should not be necessarily given to all asymptomatic subjects returning from tropical endemic areas, as is generally suggested for particular groups at risk.

Malaria surveillance in Italy : 1986-1996 analysis and 1997 provisional data.

A surveillance system for malaria was established in Italy to prevent a possible return of disease transmission after the eradication. Reporting malaria and 43 other infectious diseases is mandatory. Local laboratories diagnose clinical cases of malaria m

Malaria incidence and mortality in Italy in 1999-2000.

In 1999-2000, a total of 2060 malaria cases were reported by the ISS. Most of the patients took inappropriate treatments or did not have any prophylaxis. Ninety-three per cent became infected in African malarious countries, 4% in Asian countries, and 3% in Latin America. P. falciparum accounted for 84% of the cases, followed by P. vivax (8%), P. ovale (5%), and P. malariae (2%). Deaths corresponded to an annual case fatality rate of 0.3% in 1999 and 0.5% in 2000. In general, imported malaria cases reflect the number of Italian travellers who underestimate the infection risk in Asian and Latin American malarious countries and permanent residents of African origin who visit their relatives in their native countries.

Malaria surveillance in Italy: 1997 analysis and 1998 provisional data.

Malaria is the commonest imported infectious disease in Italy. Malaria was endemic throughout much of the country until it was eradicated nearly 50 years ago. Since then, a malaria surveillance system has been set up to detect locally acquired cases that

[Combined antimalarial therapy using artemisinin]. / Terapia antimalarica combinata con derivati dell'artemisinina.

The existing armamentarium of drugs for the treatment and prevention of malaria is limited primarily by resistance (and cross-resistance between closely related drugs). However, most of these drugs still have a place and their life-span could be prolonged if better deployed and used, and also by rationally combining them based on pharmacodynamic and pharmacokinetic properties. Newer compounds are also being developed. The nature of malaria disease and its prevalence in the developing world call for innovative approaches to develop new affordable drugs and to safeguard the available ones. According to WHO, the concept of combination therapy is based on the synergistic or additive potential of two or more drugs, to improve therapeutic efficacy and also delay the development of resistance to the individual components of the combination. Combination therapy (CT) with antimalarial drugs is the simultaneous use of two or more blood schizontocidal drugs with independent modes of action and different biochemical targets in the parasite. In the context of this definition, multiple-drug therapies that include a nonantimalarial drug to enhance the antimalarial effect of a blood schizontocidal drug are not considered combination therapy. Similarly, certain antimalarial drugs that fit the criteria of synergistic fixed-dose combinations are operationally considered as single products in that neither of the individual components would be given alone for anti-malarial therapy. An example is sulfadoxine-pyrimethamine. Artemisinin-based combination therapies have been shown to improve treatment efficacy and also contain drug resistance in South-East Asia. However, major challenges exist in the deployment and use of antimalarial drug combination therapies, particularly in Africa. These include: 1) the choice of drug combinations best suited for the different epidemiological situations; 2) the cost of combination therapy; 3) the timing of the introduction of combination therapy; 4) the operational obstacles to implementation, especially compliance. As a response to increasing levels of antimalarial resistance, the World Health Organization (WHO) recommends that all countries experiencing resistance to conventional monotherapies, such as chloroquine, amodiaquine or sulfadoxine/pyrimethamine, should use combination therapies, preferably those containing artemisinin derivatives (ACTs--artemisinin-based combination therapies) for malaria caused by Plasmodium falciparum. There is a promising role of such compounds in replacing or complementing current options. Since 1979, several different formulations of artemisinin and its derivatives have been produced and studied in China in several thousand patients for either P. falciparum or P. vivax malaria. To date, there is no evidence of drug resistance to these compounds. The use of artemisinin, artemether, arteether and artesunate for either uncomplicated or severe malaria is now spreading through almost all malarious areas of the world, although some of they have no patent protection, their development (with few exceptions) has not followed yet full international standards. Both artesunate, artemether and arteether are rapidly and extensively converted to their common bioactive metabolite, dihydroarte-misinin. WHO currently recommends the following therapeutic options: 1) artemether/lumefantrine; 2) artesunate plus amodiaquine; 3) artesunate plus sulfadoxine/pyrimethamine (in areas where SP efficacy remains high); 4) artesunate plus mefloquine (in areas with low to moderate transmission); and 5) amodiaquine plus sulfadoxine/pyrimethamine, in areas where efficacy of both amodiaquine and sulfadoxine/pyrimethamine remains high (mainly limited to countries in West Africa). This non artemisinin-based combination therapy is reserved as an interim option for countries, which, for whatever reason, are unable immediately to move to ACTs.

Permethrin-impregnated curtains against phlebotomine sandflies (Diptera: Psychodidae): laboratory and field studies.

The efficacy of permethrin-impregnated nets against vectors of leishmaniases was evaluated in laboratory and field studies. Permethrin-impregnated curtains were tested at different dosages in experimental tunnel against Phlebotomus perniciosus and P. papatasi. The influence on feeding behaviour and the mortality rate post contact with the impregnated curtain were investigated. The vapour effect of permethrin on P. perniciosus adults confined less than 1 cm away from a treated net was also evaluated. From laboratory studies it seems that permethrin shows low or any barrier effect against sandfly species tested, and that the high insecticidal activity (mortality rate greater than 90%, 24 hours after the contact with treated net, 1 g/m2) and the reduction of biting rate observed (between 53.56% and 85.24%) are the main effects that make permethrin-impregnated nets very effective for sandfly control. In field studies carried out in cutaneous leishmaniasis foci of Italy, it was demonstrated that permethrin-impregnated curtains around windows and around CDC light traps, reduce the number of sandflies entering the stables and traps. In Burkina Faso, indoor use of wide-mesh cotton curtains impregnated with permethrin 1 g/m2 almost completely eliminate the occurrence of endophilic sandfly species. In conclusion the use of permethrin-impregnated curtains could be an alternative to residual house-spraying for the control of endophilic vectors of leishmaniases.

[Preliminary studies on levels of sensitivity to phosphoric esters in the Italian population of the Culex pipiens complex]. / Osservazioni preliminari sui livelli di sensibilità agli esteri fosforici in popolazioni italiane del complesso Culex pipiens.

A preliminary survey of the susceptibility level to organophosphate (OP) insecticides in six populations of Culex pipiens from Central Italy has been carried out. The correlation between OP resistance and highly active esterase electromorphs has also been investigated. The bioassay and electrophoresis results show an association between OP resistance and the highly active esterase allele Est-3A and confirm what it was found in populations of C. pipiens from Southern France. Est-3A appears to be a reliable indicator of OP resistance in mosquitoes of italian C. pipiens.

Insecticide susceptibility levels of Anopheles gambiae s.l. in the area of Ouagadougou, Burkina Faso.

Tests to evaluate the susceptibility level in Anopheles gambiae s.1. from Ouagadougou and two nearby villages have been carried out. Anopheles gambiae s.1. larvae from Ouagadougou showed complete susceptibility to organophosphates and carbamates, and adults showed low-level resistance to DDT. Nine percent survival of adult An. gambiae s.1. to one-hour exposure of 4% DDT was observed in samples from Zagtouli village while in those from Koubri village, where dieldrin also was tested, resistance to both organochlorine insecticides was detected.

Re-emerging malaria in the WHO European region: control priorities and constraints.

Malaria has been identified by some of the countries in the European Region of the World Health Organization as a priority, due to the re-emergence of the problem. This paper aims to present the situation of indigenous malaria in the Region and the strategy to be adopted to roll back malaria.

Laboratory and field efficacy of Bacillus thuringiensis var. Israelensis and Bacillus sphaericus against Anopheles gambiae s.l. and Culex quinquefasciatus in Ouagadougou, Burkina Faso.

Two wettable powders (Bactimos and Vectobac) and one flowable concentrate (Teknar) of Bacillus thuringiensis var. israelensis (B.t.i.) and primary powders of Bacillus sphaericus isolates 1593 and 2362 were evaluated (laboratory) against field-collected larvae of Anopheles gambiae s.l. and Culex quinquefasciatus in Ouagadougou, Burkina Faso. Bactimos, Vectobac and a Corn-cob B.t.i. formulation (ABG-6138G) were field tested against Cx. quinquefasciatus and An. gambiae s.l. The isolates of B. sphaericus were also tested against An. gambiae s.l. in artificial ponds. Both wettable powders of B.t.i. showed superior activity than the flowable concentrate formulation against An. gambiae s.l. in the laboratory. Culex quinquefasciatus was more susceptible (3-4X) to B.t.i. (Bactimos) than An. gambiae s.l. The isolates of B. sphaericus were more effective (2-3X) against both mosquito species than Bactimos. In a ditch and two channels, Bactimos, Vectobac and ABG-6138G at 0.65, 1.5 and 5.6 kg/ha, respectively, gave 91-100% control of Cx. quinquefasciatus within 3 days of treatment. The same formulations at rates ranging from 0.25 to 5.6 kg/ha, produced 82-97% control of An. gambiae s.l. in rainwater pools 24 h after treatment. Isolates 1593 and 2362 at 0.12 and 0.24 kg/ha gave excellent control of An. gambiae s.l. in artificial ponds.

First record of Aedes albopictus establishment in Italy.

In September 1991, the first breeding populations of Aedes albopictus were discovered in Veneto Region, Italy. Larvae were collected in a wide variety of peridomestic containers and in used tires. Attempts were made to eradicate this species from infested areas. No larvae or adults of Ae. albopictus were found from October 1991 onwards. It is not yet assessed if this was because of the control measures taken or due to the low fall temperatures and the short critical photoperiod prevailing in the area (L:D, 12:45). Since tire casings are believed to be the primary mode of introduction and dispersal of Ae. albopictus, an investigation of tire retreading operations was initiated to determine the source and mode of introduction of Ae. albopictus into Italy.

Field trials of Bacillus thuringiensis H-14 and Bacillus sphaericus (strain 2362) formulations against Anopheles arabiensis in the central highlands of Madagascar.

Malaria is highly endemic and unstable in the central Highlands plateau of Madagascar. The infection is seasonally transmitted by Anopheles funestus and An. arabiensis. The latter species is abundant especially in rice-growing areas. The field efficacies of commercial formulations of Bacillus thuringiensis H-14 and B. sphaericus (strain 2362) were assessed against An. arabiensis in 5 types of larval habitats. The granular formulation of B. thuringiensis (Vectobac GR) provided very good control in small ponds and rainwater ditches. In ricefields complete larval control was achieved with Vectobac GR and the flowable concentrate (Vectobac 12AS) at 2.5 kg/ha and 0.6 liter/ha, respectively. The granular formulation of B. sphaericus (ABG 6185) showed activity similar to that of Vectobac GR in small pools and ricefields. ABG 6185 was less effective in rainwater ditches where it gave satisfactory control at rates not lower than 6 kg/ha.

Studies on insecticide susceptibility of Anopheles gambiae s.1. and Culex quinquefasciatus in the area of Ouagadougou, Burkina Faso (west Africa).

Tests to evaluate the susceptibility level in Anopheles gambiae s.1. and Culex quinquefasciatus from Ouagadougou and two nearby villages have been carried out. Anopheles gambiae s.1. larvae from Ouagadougou showed complete susceptibility to organophosphates and carbamates, and adults showed low level resistance to DDT. Nine percent survival of adult An. gambiae s.1. to one hour exposure of 4% DDT was observed in samples from Zaghtouli village while in those from Koubri village, where dieldrin also was tested, resistance to both organochlorine insecticides was detected. Culex quinquefasciatus showed susceptibility to fenthion, malathion, fenitrothion, and chlorpyrifos, whereas incipient resistance to temephos was detected. Electrophoretic analysis showed polymorphism of high and low active esterases (Est-2 + Est-3) confirming the association between OP resistance and enhanced esterase activity in this species.

Occurrence and spread in Italy of Aedes albopictus, with implications for its introduction into other parts of Europe.

Aedes albopictus is considered second only to Ae. aegypti in its importance to man as a disease vector of dengue and dengue hemorrhagic fever. The first sighting in 1979 of the vector species in Europe came from Albania; however, it was only when Ae. albopictus was introduced into Italy in 1990, through the importation of used tires, followed by its subsequent spread, that the species was considered as a threat to public health. At the close of 1995, Ae. albopictus infestations have been reported from 10 Italian regions and 19 provinces. The risk for greater distribution of Ae. albopictus in Europe can potentially be projected, based on well-established criteria such as: where the winter monthly mean temperature is 0 degree C, where at least 50 cm of mean annual rainfall occurs, and where the mean summer temperature is approximately 20 degrees C. Those countries where climatic conditions meet such criteria and that may be vulnerable to a potential introduction of Ae. albopictus include Spain, Portugal, Greece, Turkey, France, Albania, and the former Republic of Yugoslavia. The Italian plan of action, established for the surveillance and control of Ae. albopictus, is presented in detail.