15.1: Arthropod-Borne Viral Diseases

There are a number of arthropod-borne viruses, or arboviruses, that can cause human disease. Among these are several important hemorrhagic fevers transmitted by mosquitoes. We will discuss three that pose serious threats: yellow fever, chikungunya fever, and dengue fever.

Yellow Fever

Yellow fever was once common in the US and caused several serious outbreaks between 1700 and 1900.^[1] Through vector control efforts, however, this disease has been eliminated in the US. Currently, yellow fever occurs primarily in tropical and subtropical areas in South America and Africa. It is caused by the yellow fever virus of the genus Flavivirus (named for the Latin word flavus meaning yellow), which is transmitted to humans by mosquito vectors. Sylvatic yellow fever occurs in tropical jungle regions of Africa and Central and South America, where the virus can be transmitted from infected monkeys to humans by the mosquitoes Aedes africanus or Haemagogus spp. In urban areas, the Aedes aegypti mosquito is mostly responsible for transmitting the virus between humans.

Most individuals infected with yellow fever virus have no illness or only mild disease. Onset of milder symptoms is sudden, with dizziness, fever of 39–40 °C (102–104 °F), chills, headache, and myalgias. As symptoms worsen, the face becomes flushed, and nausea, vomiting, constipation, severe fatigue, restlessness, and irritability are common. Mild disease may resolve after 1 to 3 days. However, approximately 15% of cases progress to develop moderate to severe yellow fever disease.^[2]

In moderate or severe disease, the fever falls suddenly 2 to 5 days after onset, but recurs several hours or days later. Symptoms of jaundice, petechial rash, mucosal hemorrhages, oliguria (scant urine), epigastric tenderness with bloody vomit, confusion, and apathy also often occur for approximately 7 days of moderate to severe disease. After more than a week, patients may have a rapid recovery and no sequelae.

In its most severe form, called malignant yellow fever, symptoms include delirium, bleeding, seizures, shock, coma, and multiple organ failure; in some cases, death occurs. Patients with malignant yellow fever also become severely immunocompromised, and even those in recovery may become susceptible to bacterial superinfections and pneumonia. Of the 15% of patients who develop moderate or severe disease, up to half may die.

Diagnosis of yellow fever is often based on clinical signs and symptoms and, if applicable, the patient’s travel history, but infection can be confirmed by culture, serologic tests, and PCR. There are no effective treatments for patients with yellow fever. Whenever possible, patients with yellow fever should be hospitalized for close observation and given supportive care. Prevention is the best method of controlling yellow fever. Use of mosquito netting, window screens, insect repellents, and insecticides are all effective methods of reducing exposure to mosquito vectors. An effective vaccine is also available, but in the US, it is only administered to those traveling to areas with endemic yellow fever. In West Africa, the World Health Organization (WHO) launched a Yellow Fever Initiative in 2006 and, since that time, significant progress has been made in combating yellow fever. More than 105 million people have been vaccinated, and no outbreaks of yellow fever were reported in West Africa in 2015.

Micro Connections

Yellow Fever: Altering the Course of History

Yellow fever originated in Africa and is still most prevalent there today. This disease is thought to have been translocated to the Americas by the slave trade in the 16th century.^[3] Since that time, yellow fever has been associated with many severe outbreaks, some of which had important impacts upon historic events.

Yellow fever virus was once an important cause of disease in the US. In the summer of 1793, there was a serious outbreak in Philadelphia (then the US capitol). It is estimated that 5,000 people (10% of the city’s population) died. All of the government officials, including George Washington, fled the city in the face of this epidemic. The disease only abated when autumn frosts killed the mosquito vector population.

In 1802, Napoleon Bonaparte sent an army of 40,000 to Hispaniola to suppress a slave revolution. This was seen by many as a part of a plan to use the Louisiana Territory as a granary as he reestablished France as a global power. Yellow fever, however, decimated his army and they were forced to withdraw. Abandoning his aspirations in the New World, Napoleon sold the Louisiana Territory to the US for $15 million in 1803.

The most famous historic event associated with yellow fever is probably the construction of the Panama Canal. The French began work on the canal in the early 1880s. However, engineering problems, malaria, and yellow fever forced them to abandon the project. The US took over the task in 1904 and opened the canal a decade later. During those 10 years, yellow fever was a constant adversary. In the first few years of work, greater than 80% of the American workers in Panama were hospitalized with yellow fever. It was the work of Carlos Finlay and Walter Reed that turned the tide. Taken together, their work demonstrated that the disease was transmitted by mosquitoes. Vector control measures succeeded in reducing both yellow fever and malaria rates and contributed to the ultimate success of the project.

Dengue Fever

The disease dengue fever, also known as breakbone fever, is caused by four serotypes of dengue virus called dengue 1–4. These are Flavivirus species that are transmitted to humans by A. aegypti or A. albopictus mosquitoes. The disease is distributed worldwide but is predominantly located in tropical regions. The WHO estimates that 50 million to 100 million infections occur yearly, including 500,000 dengue hemorrhagic fever (DHF) cases and 22,000 deaths, most among children.^[4] Dengue fever is primarily a self-limiting disease characterized by abrupt onset of high fever up to 40 °C (104 °F), intense headaches, rash, slight nose or gum bleeding, and extreme muscle, joint, and bone pain, causing patients to feel as if their bones are breaking, which is the reason this disease is also referred to as breakbone fever. As the body temperature returns to normal, in some patients, signs of dengue hemorrhagic fever may develop that include drowsiness, irritability, severe abdominal pain, severe nose or gum bleeding, persistent vomiting, vomiting blood, and black tarry stools, as the disease progresses to DHF or dengue shock syndrome (DSS). Patients who develop DHF experience circulatory system failure caused by increased blood vessel permeability. Patients with dengue fever can also develop DSS from vascular collapse because of the severe drop in blood pressure. Patients who develop DHF or DSS are at greater risk for death without prompt appropriate supportive treatment. About 30% of patients with severe hemorrhagic disease with poor supportive treatment die, but mortality can be less than 1% with experienced support.^[5]

Diagnostic tests for dengue fever include serologic testing, ELISA, and reverse transcriptase-polymerase chain reaction (RT-PCR) of blood. There are no specific treatments for dengue fever, nor is there a vaccine. Instead, supportive clinical care is provided to treat the symptoms of the disease. The best way to limit the impact of this viral pathogen is vector control.

Chikungunya Fever

The arboviral disease chikungunya fever is caused by chikungunya virus (CHIKV), which is transmitted to humans by A. aegypti and A. albopictus mosquitoes. Until 2013, the disease had not been reported outside of Africa, Asia, and a few European countries; however, CHIKV has now spread to mosquito populations in North and South America. Chikungunya fever is characterized by high fever, joint pain, rash, and blisters, with joint pain persisting for several months. These infections are typically self-limiting and rarely fatal.

The diagnostic approach for chikungunya fever is similar to that for dengue fever. Viruses can be cultured directly from patient serum during early infections. IFA, EIA, ELISA, PCR, and RT-PCR are available to detect CHIKV antigens and patient antibody response to the infection. There are no specific treatments for this disease except to manage symptoms with fluids, analgesics, and bed rest. As with most arboviruses, the best strategy for combating the disease is vector control.

Link to Learning

Use this interactive map to explore the global distribution of dengue.

Exercise \(\PageIndex{2}\)

1. Name three arboviral diseases and explain why they are so named.
2. What is the best method for controlling outbreaks of arboviral diseases?

Key Concepts and Summary

• Arboviral diseases such as yellow fever, dengue fever, and chikungunya fever are characterized by high fevers and vascular damage that can often be fatal.
• Although there is a vaccine available for yellow fever, treatments for patients with yellow fever, dengue, and chikungunya fever are limited to supportive therapies.
• Vector control and animal reservoir control remain the best defenses against most viruses that cause diseases of the circulatory system.

Footnotes

1. Centers for Disease Control and Prevention. “History Timeline Transcript.” http://www.cdc.gov/travel-training/local/HistoryEpidemiologyandVaccination/HistoryTimelineTranscript.pdf. Accessed July 28, 2016.
2. Centers for Disease Control and Prevention. “Yellow Fever, Symptoms and Treatment.” 2015 http://www.cdc.gov/yellowfever/symptoms/index.html. Accessed July 28, 2016.
3. J.T. Cathey, J.S. Marr. “Yellow fever, Asia and the East African Slave Trade.” Transactions of the Royal Society of Tropical Medicine and Hygiene 108, no. 5 (2014):252–257.
4. Centers for Disease Control and Prevention. “Dengue, Epidemiology.” 2014. http://www.cdc.gov/dengue/epidemiology/index.html. Accessed July 28, 2016.
5. C.R. Pringle “Dengue.” MSD Manual: Consumer Version. https://www.msdmanuals.com/home/infections/viral-infections/dengue. 2016. Accessed Sept 15, 2016.