Training for health professionals

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Training for health professionals

• Module vector borne diseases

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Introduction

• The incidence of vector-borne diseases (VBD) in
  Europe is much greater than is generally
  recognized
• As a result, diagnosis and treatment are often
  delayed
• Health authorities often fail to allocate funding
  for the surveillance and control

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VBD climate change in Europe
Tick-borne Mosquito-borne Other insect-borne
Lyme disease Chikungunya / Dengue Leishmaniasis
Tick-borne encephalitis Malaria Chandipura virus
Human ehrlichiosis West Nile virus Sicilian virus
Tularaemia Tularaemia Tularaemia
Crimean-Congo Yellow fever Toscana virus
Sindbis viurs
Tahyna virus
This disease is currently not present in Europe
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Module vector-borne diseases

• Training topics
• Tick borne diseases
• West Nile fever (mosquito borne)
• Dengue fever (mosquito borne)
• Chikungunya fever (mosquito borne)
• Leishmaniasis (sandfly borne)

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Outline training

• Objective
• Definitions
• Effect climate change on VBD
• Specific information for each VBD (top-5)
• Health effects
• Current situation
• Future situation
• Actions needed
• Summary

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Training objective

• To learn how to be prepared for changes in public
  health due to climate change
• Take home message
• Health impact
• Mitigation and adaptation
• Preventive measures on individual community
  level

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Definitions 1

• Mitigation reducing the severity of climate
  change (reducing greenhouse gas concentrations)
• Adaptation preparing for change (adjusting our
  systems to reduce harm from climate effects)

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Definitions 2

• Vector-borne disease (VBD) an illness caused by
  an infectious microorganism (pathogen) that is
  transmitted to people by a vector, usually
  arthropods
• Arthropod an invertebrate animal having an
  exoskeleton (e.g. insects or arachnids)

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Definitions 3

• Types of VBD transmission
• Anthroponotic infections
• Mosquitoes (Malaria), Ticks (Lyme disease)
• Zoonotic infections
• Rodents (plague), Birds (Q-fever)

• Types of VBD transmission
• Anthroponotic infections
• Mosquitoes (Malaria), Ticks (Lyme disease)

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Definitions 4

• Common (arthropod) vectors
• Ticks
• Mosquitoes
• Sandflies

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VBD climate change

• Climate change will affect the distribution of
  VBD in three ways
• directly, by the effect on virus/parasite
  development and vector competence
• indirectly, by the effect on the range and
  abundance of the species that act as vectors
• indirectly, through socio-economic changes that
  affect the amount of human contact with the
  transmission cycles

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VBD climate change

• Most important climate factors
• Temperature
• Precipitation

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Temperature effects

• Vector
• Survival decrease/increase depending on the
  species
• Changes in rate of vector population growth
• Changes in the susceptibility of vectors to some
  pathogens
• Changes in feeding rate and host contact

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Temperature effects

• Example
• Summer more days with high(er) temperature
• Longer lifespan
• Longer reproduction period
• Longer activity period
• Winter less days with low temperature
• Benefits overwintering
• Shorter overwintering

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Temperature effects

• Pathogen
• Decreased extrinsic incubation period of pathogen
  in vector at higher temperatures
• Changes in the transmission season
• Changes in geographical distribution
• Decreased viral replication

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Precipitation effects

• Vector
• Survival increased rain may increase larval
  habitat
• Excess rain can eliminate habitat by flooding
• Low rainfall can create habitat as rivers dry
  into pools (dry season mosquitoes)
• Decreased rain can increase container-breeding
  mosquitoes by forcing increased water storage

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Precipitation effects

• Vector (continued)
• Heavy rainfall events can synchronize vector
  host-seeking and virus transmission
• Increased humidity increases vector survival and
  vice-versa
• Pathogen
• Few direct effects but some data on humidity
  effects on parasite development

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Summary effects climate change

• Climate change has the potential to
• Increase range or abundance of animal reservoirs
  and/or arthropod vectors
• Enhance transmission
• Increase importation of vectors or pathogens

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Module vector borne diseases

• Tick-borne diseases

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Tick-borne diseases

• Ticks are a distinct group of mites
• As blood feeding parasites, ticks are able to
  transmit a wide variety of pathogens
• This may cause tick-borne infections and diseases
  affecting
• Animals
• Humans

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Tick-borne diseases

• Stages of the tick life-cycle
• Egg
• Larva
• Nymph
• Adult
• Ticks can transmit disease during the three last
  life-cycle stages.

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Tick-borne diseases

• Tick-borne diseases to be aware of in Europe
  include
• Lyme borreliosis (LB)
• Tick-borne encephalitis (TBE)
• Tick-borne relapsing fever (TBRF)
• Crimean-Congo haemorrhagic fever (CCHF)

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Current situation - ticks

• In Europe, 90 to 95 of all tick bite incidences
  in humans are caused by
• Ixodes ricinus
• Ixodes persulcatus

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Current situation

• Yearly number of cases in Europe
• Lyme borreliosis 85,000
• Tick-borne encephalitis 5,000-8,000
• Tick-borne relapsing fever rare
• Crimean-Congo haemorrhagic fever
• endemic in Bulgaria since 1950 (50-08 1,568
  cases 17 mortality), recently new areas

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Climate ticks

• Climate suitability for the tick I. ricinus
• - Stable trends

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Climate ticks

• Climate suitability for the tick I. ricinus
• - Random trends

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Future situation ticks

• Climate change
• Distribution to higher latitudes and altitudes
• Climate conditions
• Temperature
• During summer temperature gt 5-8 ºC
• During winter high enough to continue life cycle
• Humidity
• Sufficient to prevent both eggs and ticks from
  drying out

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Tick borne disease

• - Lyme borreliosis -

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Lyme borreliosis (LB)

• Lyme borreliosis a bacterial infection caused
  by member of the genus Borrelia
• Vector borne
• Bite by infected tick (B. burgdorferi)
• Tick species I. ricinus (Europe)
• Bacteria resevoir host
• many species of small mammals
• ground-feeding birds

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LB health symptoms

• Health symptoms
• Local skin rash (80-90 of cases)
• Neuroborreliosis (main complication, 10)
• Meningoencephalitis (less common)
• Risk groups
• All persons exposed to risk of tick bites are at
  risk of becoming infected.

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LB geographical distribution

• In Europe, the mean prevalence of B.
  burgdorferi infected ticks is about 12
• Regions with highest tick infection rates are
  located in central Europe
• Austria, Czech Republic, Southern Germany,
  Switzerland, Slovakia and Slovenia
• Nymphs gt 10, adults gt 20

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LB - available warning systems

• Lyme borreliosis is not a notifiable disease in
  the European Union (in contrast to USA)
• No licensed vaccine is currently available
• Main methods of preventing infection are avoiding
  tick bites and early removal of attached ticks.

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Tick borne disease

• - Tick-borne encephalitis -

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Tick-borne encephalitis (TBE)

• Tick-borne encephalitis disease caused by a
  virus of the Flaviviridae family
• Vector borne
• Bite by infected tick
• Tick species I. ricinus (Europe)
• Virus reservoir host
• Mainly small rodents
• Also insectivores and carnivores

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TBE transmission mode

• Other transmission modes
• By consumption of infected unpasteurised dairy
  products.
• Not directly from human to human, apart from
  mother to the foetus
• Laboratory accidents (needle-stick injuries or
  aerosol infection)

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TBE health symptoms

• Health symptoms
• Two third of human TBE virus infections is
  asymptomatic
• Clinical cases
• 1st fase nonspecific symptoms (fever, fatigue
  etc.)
• 2nd fase central nervous system affected
• Several TBE virus infection subtypes
• European, Far Eastern, Siberian

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TBE health symptoms

• European subtype
• Milder compared to other subtypes
• 20-30 of patients experiencing the 2nd phase
• Severe neurological sequelae in 10 of patients
• Mortality rate 0.5-2
• Risk groups
• All persons exposed to risk of tick bites are at
  risk of becoming infected.

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TBE geographical distribution

• TBE has become a growing public health challenge
  in Europe and other parts of the world
• The number of human cases of TBE in all endemic
  regions of Europe has increased by almost 400 in
  the last 30 years
• The risk areas have spread and new foci have been
  discovered

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TBE geographical distribution

• TBE is present in
• Southern Scandinavia
• Central and Eastern Europe
• Risk of contracting the disease from a single
  bite is 1 in 600 in endemic regions

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TBE - available warning systems

• Notifiable disease in 16 European countries,
  including
• 13 European Union (EU) Member States
• 3 non-EU Member States
• A vaccine is available
• People at high risk of an infection are
  vaccinated in Sweden and other countries

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Tick borne disease

• - Tick-borne relapsing fever -

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Tick-borne relapsing fever (TBRF)

• TBRF a bacterial infection caused by member of
  the genus Borrelia
• Vector borne
• Bite by infected tick
• Tick species Ornithodoros
• Bacteria reservoir host
• Ticks
• Small mammals/birds/reptiles/bats

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TBRF health symptoms

• Health symptoms
• High fever (gt 39-40C)
• Other symptoms include
• Intensive asthenia, headache, arthralgia,
  myalgia, neck stiffness, stomach ache and nausea.
• Splenomegaly and hepatomegaly, usually associated
  with jaundice, and elevated pulse and blood
  pressure are common.
• Following the initial fever episode further
  relapses will occur

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TBRF risk groups

• Two epidemiological types of TBRF have been
  described
• Sporadic TBRF
• Observed in at-risk groups like soldiers,
  hunters, campers, field workers or travellers
• Developed countries
• Endemic TBRF
• Caused by rare but regular contact with infected
  ticks directly living in rural human dwellings
• Developing countries

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TBRF geographical distribution

• The greatest endemic risk in Europe lies in the
  Iberian Peninsula, particularly in the
  Mediterranean part, and in Asia Minor
• Reports of imported TBRF cases have come from the
  UK, Belgium and France
• The number of cases is underestimated because
  most infections are benign, and no diagnosis is
  made

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TBRF available warning systems

• TBRF is not a notifiable disease in the European
  Union
• No licensed vaccine is currently available
• Main methods of preventing infection are
• Avoiding tick-infested areas
• Avoiding tick bites

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TBRF available warning systems

• Main methods of preventing infection (continued)
• Removal or decreasing tick vectors and natural
  vertebrate reservoirs from buildings
• Chemical treatments
• Natural predators like domestic cats
• Limiting rodent-friendly environments inside and
  around buildings

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Tick borne disease

• - Crimean-Congo haemorrhagic fever -

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Crimean-Congo haemorrhagic fever (CCHF)

• CCHF a viral infection caused by the genus
  Nairovirus, Bunyaviridae family
• Vector borne
• Bite by infected tick (nymph or adult)
• Tick species Hyalomma
• Virus resevoir host
• Immature ticks hares and hedgehogs
• Mature ticks domestic animals (cattle etc.)

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CCHF transmission mode

• Other transmission mode
• direct contact with infected blood or body fluids
• contaminated medical equipment or supply

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CCHF- health symptoms

• Health symptoms
• A sudden onset of febrile illness with headache,
  myalgia, backache and joint pain, abdominal pain
  and vomiting.
• Frequently followed by
• Haemorrhagic manifestations
• Necrotic hepatitis may occur
• Large ecchymosis and uncontrolled bleeding from
  venipuncture sites are common features.

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CCHF health symptoms

• Mortality rate of CCHF is 30 with death
  occuring in the 2nd week of illness
• Risk groups
• Farmers, veterinarians and abattoir workers in
  endemic areas
• Healthcare workers (when nursing CCHF patients)
• Outdoor activities in endemic areas

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CCHF - geographic distribution

• The geographic range of CCHF virus is known to be
  the most extensive of the tick borne viruses
  important to human health.
• In Europe, cases have been reported from Albania,
  Bulgaria, Kosovo, Turkey and the former Soviet
  Union
• In Greece, the first human case of CCHF infection
  was reported 2008

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CCHF available warning systems

• CCHF is not a notifiable disease on European
  Union level
• No validated specific antiviral therapy for CCHF.
• Main methods of preventing infection are
• Avoiding tick-infested areas
• Avoiding tick bites

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CCHF available warning systems

• Main methods of preventing infection (continued)
• Removal or decreasing tick vectors and natural
  vertebrate reservoirs from buildings
• Chemical treatments
• Natural predators like domestic cats
• Limiting rodent-friendly environments inside and
  around buildings

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Summary tick borne diseases

• Tick borne disease climate change
• Distribution to higher latitudes and altitudes
• Tick-borne diseases to be aware of in Europe
• Lyme borreliosis
• Tick-borne encephalitis
• Tick-borne relapsing fever
• Crimean-Congo haemorrhagic fever

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What actions are needed?

• Public health surveillance at the European level
  (compulsory notification system in all countries)
• Educate the public on interventions against ticks
• Further research on tick distribution

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Module vector borne diseases

• Mosquitoes borne diseases
• West Nile Dengue - Chikungunya

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Mosquitoes-borne

• This training
• Culex mosquitoes ? West Nile fever
• Aedes mosquitoes ? Dengue fever
• Asian Tiger mosquitoes? Chikungunya fever
• (Aedes albopictus)

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Mosquito borne disease
- West Nile fever -
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West Nile mosquito borne

• West Nile fever disease caused by a virus of
  the Flaviviridae family (West Nile virus, WNV)
• Vector borne
• Bites of infected mosquitoes
• Culex mosquitoes species
• Virus reservoir host
• Birds

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West Nile transmission mode

• Direct transmission between animals has been seen
  experimentally
• Infected humans and horses do not seem to spread
  the virus to other mammals
• Person-to-person transmission has not been
  reported
• In rare cases, the virus has been spread by blood
  transfusions, organ transplants, and
  transplacental transmission

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West Nile health effects

• Asymptomatic infections (80)
• Clinical symptoms
• Mild
• Flu-like symptoms, including fever, headache and
  body aches.
• Most uncomplicated infections resolve in 3-6 days
• Severe clinical cases
• Neuro-invasive disease there may be signs of
  encephalitis, meningo-encephalitis or meningitis.

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West Nile health effects

• An estimated 1 out of 140 - 320 infections
  results in meningitis or encephalitis.
• The case fatality rate in patients with
  neuro-invasive illness ranges from 4 to 14 it
  can reach 1529 in patients over 70 years old.
• Concurrent disorders such as diabetes or
  immunosuppression increases the risk of death.

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West Nile mosquito borne

• Culex species (Cx. spp.)
• Large number of spp. world wide (gt 700)
• About 20 spp. are present in Europe
• Infection and transmission rates are variable
• Example mosquitoes from the Rhone delta, France
• Cx. modestus Cx. pipiens Infection
  rate 89.2 38.5
• Transmission rate 54.5 15.8

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Current situation

• Worldwide distribution Cx. mosquitoes
• Distributed worldwide
• They can be found in tropical and temperate
  climate zones on all continents except Antarctica
• Europe distribution Cx. mosquitoes
• Wetland areas of high biodiversity
• Cx. pipiens spp. urban/city dweller

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Current distribution - mosquito
Distribution of the Culex pipiens complex and its
sibling species Source Smith 2004
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West Nile health impact

• West Nile Fever worldwide
• West Nile Fever is distributed worldwide
• Outbreaks may occur in humans, birds, and horses
  in Africa, Europe, Russia, India, and Australia
• West Nile Fever Europe
• Erratic and spatially and temporally limited
  phenomena
• Occurring quite unpredictably, even if all
  conditions appear to be present in a definite
  place

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West Nile health impact

• Risk groups
• People over 50 years old are at higher risk of
  developing severe neurological disease and should
  take special care to avoid mosquito bites.

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Current distribution West Nile
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Available warning systems
Country Control measures
Greece Enhanced surveillance for human cases Adulticiding (ultra-low volume spraying) of mosquitoes in villages with human cases Public education campaigns for personal protection Education and guidance to school teachers and health care personnel
Romania Seasonal surveillance for human cases Blood safety measures
Turkey Improved surveillance (active and passive) for human cases Inclusion of WNV as a notifiable disease for 2011 season
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Available warning systems

• West Nile fever is a notifiable disease in the
  European Union
• The ECDC is responsible for the surveillance of
  infectious diseases in the European Union.

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Future situation

• Current situation Europe
• Autochthonous WNV infections in several countries
  during the transmission season
• Future situation climate change
• The dynamics of transmission of WNV are complex ?
  difficult to predict the situation for Europe in
  the coming years
• Data indicate that the epidemiology of WNV in
  Europe is changing

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What actions are needed? 1

• Development of a vaccine
• Need for integrated multidisciplinary
  surveillance systems and response plans
• Raising the awareness of clinicians and
  veterinarians of the clinical presentation of WNV
  disease in humans and horses
• Particularly during the mosquito season from June
  to October
• Primarily in areas considered as at major risk
  surrounding (irrigated areas and river deltas)

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What actions are needed? 2

• More research to
• Suitable habitats for birds that would increase
  the bird-mosquito-human interface
• Competent vector species
• Establish limits around WNV affected areas
• Identify potential new at-risk areas
• Study the cycle of transmission and the
  maintenance of WNV in the environment over the
  years

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Mosquito borne disease
- Chikungunya fever - - Dengue fever -
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Chikungunya Dengue

• Chikungunya fever disease caused by a virus of
  the Togaviridae family (CHIKV)
• Dengue fever disease caused by a virus of the
  Flaviviridae family (dengue virus DENV)
• Vector borne
• Transmitted from human to human by bites of
  infected mosquitoes

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Chikungunya Dengue

• Vector borne (continued)
• Aedes mosquitoes species (both CHIKV and DENV)
• Virus reservoir host
• Humans

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Transmission mode

• Bites of infected mosquitoes
• Direct contact with infected blood or body fluids
• Contaminated medical equipment or supply
• Can be transmitted from mother to child

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Climate change Aedes mosquitoes
- Chikungunya fever - - Dengue fever -
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Chikungunya Dengue

• Aedes mosquito species
• Ae. aegypti
• Diurnal biting habits
• Once endemic in Europe, disappeared after WWII
• Ae. albopictus (Asian tiger mosquito)
• Not host-specific
• Present in southern Europe

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Current situation

• Worldwide distribution Aedes mosquitoes
• Climate conditions
• Overwintering conditions 0C January isotherm
  with 500 mm annual rainfall
• Development monthly mean temperature 10C
• Transmission monthly mean temperature 20C
• Risk zones Chikungunya/Dengue fever
• Originally, Africa, Southeast Asia, Indian
  subcontinent and islands in the Indian Ocean
• Increasing presence of Aedes mosquitoes in
  Southern Europe ? new risk zone?

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Current distribution - mosquito
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Future situation minimum impact
Climate change long term impact on Ae.
Albopictus distribution
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Future situation maximum impact
Climate change long term impact on Ae.
Albopictus distribution
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Future situation

• Maps show the risk of establishment of Aedes
  albopictus
• The maps do not report the risk of transmitting
  exotic viruses, nor can one extrapolate from them
  to assess any such risk
• Analysing this risk would require a significant
  number of additional datasets, e.g. vector
  capacity in the given eco-climatic settings which
  are currently not available

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Mosquito borne disease
- Chikungunya -
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Chikungunya health effects

• Clinical symptoms
• Incubation time of 4-7 days (range 1-12)
• Sudden onset of high fever (gt38.5C)
• Other (flu-like) symptoms
• Headache, backpain, myalgia, arthralgia, rash
• ? Similar to Dengue fever
• Treatment
• Symptoms generally resolve within 7-10 days
• No vaccine or medication currently available

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Chikungunya health effects

• Possible complications
• Gastro-intestinal complications, cardio-vascular
  decompensation or meningo-encephalitis
• Fatalities have been reported mainly in aged
  patients or where the patients immune system was
  weakened by underlying conditions

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Chikungunya health impact

• World wide
• 52 Tanzania
• 60s Southeast Asia India 1.39 million cases
• 80s Small outbreaks Thailand lt 12,000 cases
• 01-07 Major outbreaks islands Indian Ocean
  (1/3 of population) and India 1.42 million
  cases
• Europe
• 07 outbreak in Italy ? 247 cases

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Chikungunya health impact

• Risk groups
• There are no particular risk groups anyone
  exposed to the infected vector may become
  infected with the virus
• Vulnerable population for severe illness
• Pregnant women
• Children under 12 years old
• People with immune disorders or server chronic
  illnesses

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Current distribution Chikungunya
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Available warning systems

• Chikungunya is not a notifiable disease in most
  of the European countries.
• There is no commercial chikungunya vaccine
• Prevention of chikungunya is currently based on
  individual protection against mosquito bites

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Mosquito borne disease
- Dengue fever-
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Dengue health effects

• Asymptomatic infections (40-80)
• Clinical symptoms
• Mild fever
• Classic dengue fever
• Server flu-like symptoms high fever, severe
  headache, pain behind the eyes, muscle and joint
  pains and rash
• Dengue haemorrhagic fever / Dengue shock
• lt5 of all cases, mostly children and
  adolescents
• Increase of vascular permeability that can lead
  to life-threatening hypovolemic shock

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Dengue health impact

• World wide
• 2.5 billion people (two fifths of the world's
  population) are now at risk from dengue
• WHO estimates there may be 50 million dengue
  infections every year
• Europe
• Last endemic was in 1927-78 in Greece
• However, imported cases frequently reported
  (travellers that have visited endemic areas)

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Dengue health impact

• Risk groups
• There are no particular risk groups anyone
  exposed to the infected vector may become
  infected with the virus
• Since there are four virus serotypes, it is
  possible to get dengue multiple times within a
  lifetime

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Current distribution - Dengue
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Available warning systems

• Dengue is not a notifiable disease on European
  Union level
• There is no dengue vaccine, but this is an active
  field of research
• Prevention of dengue is currently based on
  individual protection against mosquito bites

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Future situation
- Chikungunya fever - - Dengue fever -
101
Future situation

• Current situation Europe
• Mosquito biting activity is highest in
  mid-afternoon.
• Incidental, travellers that visited endemic areas
• Future situation climate change
• At present, no good prediction models available

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What actions are needed? 1

• Short term
• Providing information to all people traveling
  from the affected areas with high disease
  incidence
• Providing dengue/chikungunya virus fact sheets to
  physicians, as returning travelers may present
  with the disease,
• Reminding medical staff of the need to follow
  universally accepted precautions when handling
  samples from all patients
• Advising European Union member states on blood
  donation policies
• Assessing the capability and capacity of
  laboratories in Europe to diagnose
  dengue/chikungunya fever

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What actions are needed? 2

• Long term
• Further studies and documentation of vector
  competence and capacity of Ae. albopictus would
  be useful in areas in Europe where these vectors
  are known to be present.
• Areas at risk of vector establishment need to be
  identified and regularly monitored, and vector
  surveillance implemented or strengthened in these
  areas.
• Measures to prevent the introduction of Ae.
  albopictus through the used tyre trade and plants
  transported in water (e.g. Dracaena species)
  should be considered.

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Summary mosquito borne 1

• Aedes species (dengue and chikungunya virus)
• It can be concluded that the temperate strains of
  Aedes albopictus are here to stay and that they
  will spread (Southern Europe)
• New Aedes populations may become established in
  other parts of Europe
• Culex species (West Nile virus)
• Autochthonous transmission of West Nile fever in
  several European countries
• Data indicate that the epidemiology of WNV in
  Europe is changing

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Summary mosquito borne 2

• Actions
• Surveillance of the introduction and spread of
  this vector, in particular in areas at risk, is
  important in order to be prepared for the
  mosquitos role in the transmission of diseases
• Education of public (risk areas and travelers)
  and health professionals
• Preventive measures
• Health effects
• Treatment
• Advising European Union member states on blood
  donation policies

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Module vector borne diseases

• Leishmaniasis sandfly borne

107
Leishmaniasis sandfly borne

• Leishmaniasis disease caused by Leishmaniasis
  parasite
• Vector borne
• zoonotic or anthroponotic
• usually by the bite of a phlebotomine sandfly
  species
• Parasite reservoir hosts
• Wild animals (fox, rodents, wolves etc.)
• Domestic animals (dogs)

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Transmission mode

• Bite by an infected sandfly
• Can be transmitted from mother to child
• Contaminated medical equipment or supply (shared
  syringes)

109
Leishmaniasis health effects

• Asymptomatic leishmania infections
• Forms of leishmaniasis
• CL Cutaneous (most common)
• ML Mucocutaneous
• VL Visceral (most severe, affecting organs)
• Canine leishmaniasis (dogs)

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Leishmaniasis sandfly borne

• 500 phlebotomine species, but only about 30
  transmit leishmaniasis
• Only the female sandfly transmits the parasites
• 8 medically important in Europe

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Current situation

• Worldwide distribution of parasite sandflies
• Areas that have at least one month with a mean
  temperature of 20C
• European distribution of parasite sandflies
• South of latitude 45oN and less than 800 m above
  sea level
• Recent data suggest that the area has been
  expanded

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Current distribution sandfly
112
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Current distribution sandfly
113
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Leishmaniasis health impact

• World wide
• An estimated 12 million people are infected
• 2 million estimated new cases/year
• Europe
• Incidence of leishmaniasis in humans is
  relatively low (0.02- 0.49/100,000)
• 700 estimated new cases/year for Southern
  European countries (3,950 if Turkey is included)

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Leishmaniasis health impact

• Risk groups leishmania infections
• There are no specific risk groups for leishmania
  infections
• Risk groups leishmaniasis
• HIV-positive people (visceral leishmaniasis)
• Intravenous drug users who share syringes

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Current distribution Leishmaniasis
116
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Current distribution Leishmaniasis
Source Dujardin 2008
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Available warning systems

• Compulsory notification system
• Portugal compulsory for VL
• Spain compulsory for VL in 12/17 autonomous
  communities
• Greece compulsory for VL and CL
• Cyprus compulsory for VL and CL
• Turkey compulsory for VL and CL

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Future situation

• Current situation Europe
• Sandfly biting activity is strongly seasonal,
  restricted to summer months in most areas
• Southern Europe, below 800m above sea level
• Future situation climate change
• Prolonged activity periods and shorter diapause
  periods (overwintering)
• Extend northwards and into higher altitudes
• At present, no good prediction models available

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What actions are needed?

• Public health surveillance at the European level
  (compulsory notification system in all
  countries)?
• Educate the public on interventions against
  sandflies
• Further research

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What actions are needed?

• Interventions against sandflies
• Insect repellents such as DEET
• Insecticides
• Use of insecticide impregnated nets and bed nets
• Dog topical applications and deltamethrin-impregn
  ated collars

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What actions are needed?

• Further research on
• Alternative modes of transmission
• Effective vaccine for human leishmaniasis
• immunisation strategy for Mediterranean
  populations
• Effective vaccine for canine leishmaniasis
• to control the infections in vector reservoir
  dogs
• Better predictive modelling of disease
  transmission

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Summary sandfly borne 1

• Currently, Leishmaniasis infected sandflies are
  present in Southern Europe (max. 800m above sea
  level)
• Climate change may extend this risk area
  northwards and into higher altitudes
• Actions
• Surveillance of the introduction and spread of
  this vector

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Summary sandfly borne 2

• Actions (continued)
• Education of public (risk areas and travelers)
  and health professionals
• Preventive measures
• Health effects
• Treatment

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Module vector borne diseases

• SUMMARY

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Training objective

• To learn how to be prepared for changes in public
  health due to climate change
• Take home message
• Health impact
• Mitigation and adaptation
• Preventive measures on individual community
  level

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Summary module VBD 1

• Health impact climate change
• Tick borne disease ? highest tick infection rates
  in central Europe ? may spread to northern areas
• Mosquito borne disease ?
• West Nile virus ? spatially and temporally
  limited. However, autochthonous transmissions.
• Chikungunya ? outbreak in Italy in 2007. In
  future, Southern Europe may be at risk.

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Summary module VBD 2

• Health impact climate change (continued)
• Mosquito borne disease ?
• Dengue ? currently not present in Europe. In
  future, Southern Europe may be at risk.
• Sandfly borne disease ? Leishmaniasis is endemic
  in Southern Europe. In future, risk area may
  extend northwards and into higher altitudes

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Summary module VBD 3

• Adaptation
• Surveillance of the introduction and spread of
  the vector, in particular in areas at risk
• Providing information to all people traveling
  from the affected areas with high disease
  incidence
• Providing fact sheets to physicians
• Reminding medical staff of the need to follow
  universally accepted precautions when handling
  samples from all patients

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Summary module VBD 4

• Adaptation (continued)
• Advising European Union member states on blood
  donation policies
• Assessing the capability and capacity of
  laboratories in Europe to diagnose vector borne
  disease
• Development of vaccines

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Summary module VBD 5

• Preventive measures on individual level
• Avoiding risk areas (if possible)
• When staying in affected areas
• Wear long-sleeved shirts and long trousers, and
  trousers tucked into socks
• Use insect repellents such as DEET
• If possible, sleep under bed nets pre-treated
  with insecticides
• If possible, set the air conditioning to a low
  temperature at night

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Summary module VBD 6

• When staying in affected areas (continued)
• Good screens on windows and doors
• Remove tick within 24 hours (hard ticks)

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Summary module VBD 7

• Preventive measures on community level
• Blood donation restrictions have to be considered
  in areas where a vector borne virus is
  circulating
• Limiting vector friendly environments (next
  slides)

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Summary module VBD 8

• Ticks
• Chemical treatment
• Natural predators like domestic cats
• Limiting rodent-friendly environments inside and
  around buildings
• Acaricides may be useful on domestic animals to
  control CCHF virus-infected ticks if used 1014
  days prior to slaughter or to export of animals
  from enzootic regions

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Summary module VBD 9

• Mosquitoes
• Insecticides
• Removal of breeding sites around buildings
  emptying stagnant water in and around the houses
  on a weekly basis
• Limiting vector friendly environments -sandflies
• Dog topical applications and deltamethrin
  impregnated collars

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More information

• Websites
• www.climatetrap.eu
• www.ecdc.eu
• www.who.int/globalchange/en/

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