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Public health is better prepared for West Nile virus

Surprised by the scope of last year's outbreak, health departments are concentrating on awareness campaigns and surveillance systems.

By Victoria Stagg Elliott, amednews staff. July 14, 2003.

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With confirmation of the season's first human case of West Nile virus infection expected any day now, health officials are ready to respond.

For starters, public education campaigns have been fine-tuned to communicate the personal protection message to those who need it most.

In addition, surveillance systems are in place and have been finding infected mosquitoes and animals for months. The blood supply is poised to start screening all blood donations this month And doctors are armed with a greater degree of knowledge than ever about the damage that West Nile virus can do. They also have increased access to the lab tests that can diagnose it.

The big questions now are where will it strike hardest and whom?

Last year's outbreak stunned the public health system with its breadth and depth. No one expected it to sicken more than 4,000 and kill nearly 300 people, touching all but four of the continental United States.

"Everyone was caught blindsided," said Steven Gordon, MD, hospital epidemiologist at the Cleveland Clinic.

At press time, this year's tallies were as follows: At least 26 states were reporting West Nile-positive birds, horses or infected mosquitoes and four states were investigating suspected human cases.

"We have to keep our guard up," said Stephen Sokalski, DO, chief of infectious diseases and epidemiology at Advocate Christ Medical Center in Oak Lawn, Ill. He treated numerous cases last summer.

This year will present new challenges. Most people infected with West Nile virus never get sick, and rapid tests for the disease detect antibodies -- which can remain in the human system for months -- rather than the actual virus. Experts worry that this would confound rapid diagnosis and complicate surveillance.

In fact, one of two suspect cases in Louisiana initially tested positive. On subsequent testing, the patient did not have the virus. Public health officials concluded that the antibodies were left over from last year when he was infected but did not get sick.

"It's going to be a lot more complicated this year," said Raoult Ratard, MD, MPH, state epidemiologist at the Louisiana Dept. of Health and Hospitals. "Sometimes we will classify cases in the wrong box."

Physicians say, however, that this is unlikely to impact patient care because treatment for viral meningitis does not vary that much depending on the cause.

The other suspect cases in Washington, South Carolina and Indiana are also not likely to be confirmed -- creating a bit of a mystery for public health officials.

Some suspect that the early detection of numerous animal cases was a result of improved surveillance. Others say, though, that these early animal cases signal that there should have been human cases by now, too.

"It's a little bit of a surprise," said Dr. Ratard. "I don't think we understand enough."

Meanwhile public health departments are learning to deliver their messages about West Nile more effectively, aiming at groups most likely to become infected. Most are using the "Fight the Bite" model created by New York state and adopted by other states and the Centers for Disease Control. The Wyoming's "Bad Skeeter" campaign is also a notable standout for design and message.

"It's not necessarily a big change in message," said Emily Zielinski-Gutierrez, MPH, DrPH, a CDC behavioral scientist. "We're just making sure that we're reaching those audiences who spend a lot of time outdoors, especially those over 50."

Public health officials and other West Nile experts are also taking the opportunity to increase awareness of other mosquito-borne diseases and use tools designed to detect West Nile to find others. Some states have been detecting increasing cases of eastern equine encephalitis. It is unclear whether this boost is due to improved surveillance or a true increase.

Meanwhile, the suspect West Nile case in Washington turned out to more likely be a case of St. Louis encephalitis, something that hasn't been seen in that state for more than 30 years.

"The good news is it isn't West Nile," said Larry Jecha, MD, MPH, health officer for the Benton-Franklin health district who handled this case. "The bad news is we have another vector-borne illness in the state."

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