Reunión de centros colaboradores OMS, México DF Situación actual de arbovirus diferentes a dengue y su impacto a nivel mundial Reunión de centros colaboradores OMS, México DF 31 Agosto – 1 Septiembre 2015 Dr Sergio YACTAYO

Arbovirus Grupo de virus transmitidos por vectores artrópodos (mosquitos y tiques) De donde viene la palabra arbovirus Manifestaciones clínicas: AR thropod BO rne virus Van desde infecciones asintomáticas – enfermedad febril (artralgias, rash, hemorragias, hepatitis, encefalopatías etc) Situación sanitaria mundial muy alarmante, cambios climáticos? Pandemic and Epidemic Diseases

Arbovirus: clasificación en 4 familias Family Bunyaviridae Genus Nairovirus Crimean–Congo hemorrhagic fever virus (CCHF) Genus Orthobunyavirus Bunyamwera virus California encephalitis virus La Crosse encephalitis virus (LACV) Genus Phlebovirus Rift Valley fever virus (RVFV) Toscana virus (TOSV) Heartland virus Family Flaviviridae Genus Flavivirus Tick-borne viruses Mammalian tick-borne virus group Kyasanur forest disease virus (KFDV) Tick-borne encephalitis virus (TBEV) Mosquito-borne viruses Dengue virus group Dengue virus (DENV) Japanese encephalitis virus group Japanese encephalitis virus (JEV) Murray Valley encephalitis virus (MVEV) St. Louis encephalitis virus (SLEV) West Nile virus (WNV) Yellow fever virus group Yellow fever virus (YFV) Family Reoviridae Subfamily Sedoreovirinae Genus Orbivirus African horse sickness virus (AHSV) Bluetongue disease virus (BTV) Equine encephalosis virus (EEV) Genus Seadornavirus Banna virus (BAV) Subfamily Spinareovirinae Genus Coltivirus Colorado tick fever virus (CTFV) Family Togaviridae Genus Alphavirus Eastern equine encephalitis virus (EEE) Ross River virus (RRV) Venezuelan equine encephalitis virus (VEE) Western equine encephalitis virus (WEE) Chikungunya virus (CHIKV) Pandemic and Epidemic Diseases

Flavivirus conocidos en los humanos (Americas) Distribución Remarcas Bussuquara (BSQV) Brazil, Colombia, Panama 2 cases Ilheus virus (ILHV) C & S América Rocio virus (ROCV) Brazil Epidemic encephalitis St Louis encephalitis virus USA, Panama, Jamaica, Trinidad, Brazil, Argentina Yellow Fever Epidemias periodicas ZIKA virus Brasil, Chile emergente Dengue virus Mundialmente Tipos 1-4 West Nile virus N America Epidemias USA Pandemic and Epidemic Diseases

Flavivirus / Alfavirus emergentes en las Américas Todos los miembros del genero flavivirus están relacionados antigénicamente Las reacciones serológicas cruzadas son comunes Existen algunas vacunas (YF, DEN, CHIK….) Japanese encephalitis (JEV) Kedougou virus (KEDV) West Nile Virus (WNV) Zika virus (ZIKV) Dengue virus (DENV) Yellow fever (YFV) Chikungunya virus (CHIK) Reacciones cruzadas Pandemic and Epidemic Diseases

ZIKA: epidemias recientes En los últimos años en: 2007 Isla de Yap (Micronesia) 2014 Polinesia Francesa 2014-2015 Nueva Caledonia. Recientemente en Brasil: Desde Mayo 2015 Mas de 13 estados han reportado casos 13,000 casos sospechosos y confirmados 121 casos Síndrome de Guillan Barré y otras complicaciones neurológicas (encefalitis, mielitis, neuritis óptica) Agosto 2015 España reporto el primer caso autóctono Pandemic and Epidemic Diseases

ZIKA: Definición clínica de casos Caso sospechoso: Exantema maculo-papular y/o fiebre moderada, acompañado de 2 de los signos siguientes: Caso confirmado: por RT-PCR en sangre o orina Caso importado: Una persona en donde los síntomas han comenzado al menos 15 dias luego del regreso de una zona endémica Zika Caso grupal: aparición de al menos dos casos sospechosos en el mismo espacio y tiempo. Hiperemia conjuntival Artralgias Mialgias Ausencia de otra etiología Pandemic and Epidemic Diseases

Chikungunya: Entre 2013-2015: >1.5 millón de casos sospechosos 2.2% han sido confirmados por Laboratorio Mortalidad < 1% ….. Un incremento en los casos atípicos y crónicos. Pandemic and Epidemic Diseases

Chikungunya: Definición clínica de casos Caso clínico agudo 1) Criterio clínico: fiebre por encima de 38,5ºC y dolor articular (generalmente incapacitante) de comienzo agudo y 2) Criterio epidemiológico: residente o visitante en áreas con transmisión local de CHIKV en los últimos 15 días. (caso sospechoso a efectos epidemiológicos) o 3) Criterio de laboratorio: confirmación por laboratorio: PCR, serología o cultivo viral (caso confirmado a efectos epidemiológicos) Se acompaña generalmente de exantema, mialgia, dolor de espalda, cefalea y, ocasionalmente, vómitos y diarrea (en edad pediátrica). Pandemic and Epidemic Diseases

ZIKA y CHIK confirmación por laboratorio Método molecular: RT PCR, si muestra < 10 días. En orina mas tardio Método inmunológico: ELISA IgM / IgG títulos PRNT títulos Diagnostico diferencial: DENV, YFV Pandemic and Epidemic Diseases

Factores de riesgo Pandemic and Epidemic Diseases ECOLOGIO y MEDIO AMBIENTE Pandemic and Epidemic Diseases

Riesgo de transmisión de Aedes aegipty en el mundo VECTORES Aedes aegipty distribution

Riesgo de diseminación mundial por avión HUMANO Zones infected with Aedes aegypti New York city 16 h Miami 20 h Nelle- Orléans 22 h Sao Paulo 26 h Brisbane Sydney Bangkok Delhi 14 h The average durations of travel, including transit time, were provided par Carlson Wagons-lits ®. Abidjan Lagos, Nigeria Scenario hipotetico desde Nigeria

Puntos similares DEN, YF, ZIKA, CHIK El vector es el mismo Los factores de riesgo son similares Presentación clínica Laboratorio: reacciones cruzadas Pandemic and Epidemic Diseases

Outbreaks of YF in the Americas, XVII°-XX° centuries Massachusetts, 1801 United States of America Boston, 1691, 1693, 1694, 1803, 1821 Albany, 1734 New Haven, 1747 New York, 1668, 1694, 1702, 1734, 1743, 1745, 1751, 1791, 1801, 1819, 1821, 1822, 1870 Alabama, 1821, 1854, 1873 PhiladelphiA 1668, 1693, 1694, 1699, 1751, 1778, 1791, 1793, 1802, 1803, 1805, 1819, 1820, 1821, 1867 Mississippi, 1821, 1843, 1855, 1873, 1878 New Jersey, 1811 Memphis, 1828, 1873, 1879 Baltimore 1783, 1817, 1819, 1821 Washington, 1825 Galveston, 1839, 1843, 1867 Norfolk, 1801 VirginiA, 1741, 1743 Vera Cruz, 1699, 1725 Atlantic Ocean Gulf of Mexico Charleston, 1690, 1693, 1699, 1703, 1728, 1732, 1745, 1748, 1792, 1807, 1817, 1819, 1821, 1824, 1839, 1843, 1852, 1854, 1856, 1858, 1876 Mexico New orleans 1811, 1817, 1819, 1820, 1821, 822, 1824, 1827, 1828, 1829, 1837, 1841, 1847, 1854, 1856, 1867, 1873, 1878, 1905 Mobile, 1825, 1827, 1829, 1837, 1839, 1843, 1847,1854, 1867 Florida, 1811, 1823, 1829, 1841, 1867 South carolina, 1877 Yellow fever epidemics  WHO 2005. All rights reserved. Epidemic and Pandemic Alert and Response YELLOW FEVER INITIATIVE

Outbreaks of YF in Europe, XVII°-XIX° centuries Yellow fever epidemics London 1723 Southampton 1822 Dublin 1826 Ireland England Swansea 1865 English Channel Livorno 1804 Brest 1802, 1856 France Saint Nazaire 1861 Barcelona 1810, 1821, 1870 Atlantic Ocean Italy Cataluna 1804 Madrid 1878 Valencia 1804 Porto 1857 Cartagena 1740, 1810 Spain Cordoba 1804 Grenada 1804 Portugal Lisbon 1723, 1823, 1857 Malaga 1741, 1810 Mediterranean Sea WHO 2005. All rights reserved. Cadiz 1700, 1730, 1736, 1764, 1802, 1810 Gibraltar 1649, 1727, 1804, 1813, 1828

YF Cuban Hospital in XXth century GRACIAS YF Cuban Hospital in XXth century

Método scoring para DENV y CHIKV en Venezuela Scoring clinical / biological for DEN/CHIK differential diagnosis screening. (Thiberville SD et al. PLOS 2013 ) Initially the maximum validity period for International certificate of vaccination was 6 years In 1953 the Expert Committee on YF recommended that this validity period be extended from 6 to 9 years. It recommendation was accepted by the Committee on International Quarantine But at the 7th WHA the question was discussed. The Committee on International Quarantine change his opinion and consider there was insufficient evidence on which to base an extension of the validity period from 6 to 9 years, In 1959 the Committee on International Quarantine considered a scientific publication:Groot H. Neutralazing and Haemagglutination-Inhibiting Ab to YF 17 years after vaccination with 17D vaccine. Bull WHO. 27: 699-707. 1962. It reported the presence of seroneutralization Ab for 17 years after vaccination with 17D vaccine in 97% (N= 108) persons, living in an area where YF had never been reported. Roseonzweig It reported the presence of seroneutralization Ab up 19 years

Venezuela: Chikungunya outbreak Costo de una epidemia de CHIK en Venezuela Venezuela: Chikungunya outbreak 9.6 M días de trabajo perdidos 5.1 M consultas externas 1.5 M análisis de laboratorio 148 comprimidos de acetaminofén consumidos 1200 Pacientes hospitalizados 1,055 millón USD (costos directos e indirectos) Initially the maximum validity period for International certificate of vaccination was 6 years In 1953 the Expert Committee on YF recommended that this validity period be extended from 6 to 9 years. It recommendation was accepted by the Committee on International Quarantine But at the 7th WHA the question was discussed. The Committee on International Quarantine change his opinion and consider there was insufficient evidence on which to base an extension of the validity period from 6 to 9 years, In 1959 the Committee on International Quarantine considered a scientific publication:Groot H. Neutralazing and Haemagglutination-Inhibiting Ab to YF 17 years after vaccination with 17D vaccine. Bull WHO. 27: 699-707. 1962. It reported the presence of seroneutralization Ab for 17 years after vaccination with 17D vaccine in 97% (N= 108) persons, living in an area where YF had never been reported. Roseonzweig It reported the presence of seroneutralization Ab up 19 years Source: Castro J and Abadi A Prodavinci 2015