1. Division of Public Health Services New Hampshire Department of Health and Human Services Eastern Equine Encephalitis (EEE) in New Hampshire Dianne Donovan, BSc Arboviral Surveillance Coordinator Ddonovan@dhhs.state.nh.us (603) 271-5927

2. Division of Public Health Services New Hampshire Department of Health and Human Services EEE Transmission Cycle Mosquito vector Bird reservoir hosts

3. Division of Public Health Services New Hampshire Department of Health and Human Services EEE History 1831 – Horses in MA afflicted with an unknown encephalitis virus 1933-1935 – Multiple equine outbreaks along the eastern seaboard 1938 – 1 st human case in NE reported. MA: 34 human cases, 248 equine 1955-1959 – MA reported 16 human cases; NJ reported 33 human cases

4. Division of Public Health Services New Hampshire Department of Health and Human Services

5. Division of Public Health Services New Hampshire Department of Health and Human Services EEE

6. Division of Public Health Services New Hampshire Department of Health and Human Services NH Historical Perspective (EEE) 1973 – 75 equine deaths; 12,000 pheasant deaths 1978 – 28 equine deaths 1980 – 1 human case reported (not confirmed), 1 equine death 1982 – 1 equine death

7. Division of Public Health Services New Hampshire Department of Health and Human Services NH Historical Perspective (EEE) 2004: EEE detected in horses, birds, and mosquitoes 2005: Human cases - 7 reported human cases (2 died) - EEE detected in numerous non-human mammals, birds, and mosquitoes

8. Division of Public Health Services New Hampshire Department of Health and Human Services NH Historical Perspective (EEE) 2006: EEE detected in horse, birds, and mosquitoes 2007: 3 reported human cases - EEE detected in mosquitoes, a horse, an alpaca

9. Division of Public Health Services New Hampshire Department of Health and Human Services

10. Division of Public Health Services New Hampshire Department of Health and Human Services EEE Symptoms & Clinical Features

11. Division of Public Health Services New Hampshire Department of Health and Human Services EEE - Symptoms Incubation 4-10 days No symptoms in some people infected Severe symptoms in others - short prodrome, ~5 days (fever, headache, abdominal distress) –Progresses to disorientation, seizures, muscle weakness, paralysis, coma, death

12. Division of Public Health Services New Hampshire Department of Health and Human Services EEE - Clinical Features Common: F (83%), HA (75%), N/V (61%) < 50%: confusion, myalgia, abd pain < 10%: sore throat, diarrhea, CN palsies Imaging (CT, MRI) abnormal in two- thirds of patients Source: Deresiewicz NEJM 1997

13. Division of Public Health Services New Hampshire Department of Health and Human Services Laboratory Findings (severe neurological disease) Peripheral Blood Normal or elevated total leukocyte count Lymphocytopenia Anemia Hyponatremia

14. Division of Public Health Services New Hampshire Department of Health and Human Services Laboratory Findings (severe neurological disease) Cerebrospinal Fluid Pleocytosis (usually with a predominance of lymphoctyes) Elevated protein Normal glucose levels

15. Division of Public Health Services New Hampshire Department of Health and Human Services EEE - Diagnosis and Prognosis Diagnosis by IgM serum/CSF –Confirmation by PRNT Mortality rate 35% Neurological sequelae in 30% of survivors Lifetime expenses = $3 million/case

16. Division of Public Health Services New Hampshire Department of Health and Human Services EEE Treatment There is NO specific treatment. Care of patients centers around supportive treatment of symptoms and complications. Vaccine – only available for horses.

17. Division of Public Health Services New Hampshire Department of Health and Human Services NH EEE PATIENTS Demographic & Clinical Characteristics

18. Division of Public Health Services New Hampshire Department of Health and Human Services Demographic & Clinical Characteristics Age: Mean = 40 years Range = 4-80 years Gender: 8 males; 2 females Onset Date: Earliest = August 3 Latest = October 1

19. Division of Public Health Services New Hampshire Department of Health and Human Services Demographic & Clinical Characteristics Prodromal Signs & Symptoms: Fever9/10 Weakness9/10 Fatigue9/10 Headache8/10 Myalgias7/10 N/V7/10

20. Division of Public Health Services New Hampshire Department of Health and Human Services Demographic & Clinical Characteristics Prodrome Duration (Days): Mean – 7 days Range - <1 to ~15 days SEIZURES: 4/10 COMA: 5/10 DEATHS: 2/10

21. Division of Public Health Services New Hampshire Department of Health and Human Services Suspect Case Reporting

22. Division of Public Health Services New Hampshire Department of Health and Human Services Criteria for Report (a, b, or c) a.Any patient with viral encephalitis with - Fever > 100 F - CNS involvement - Abnormal CSF profile suggesting a viral etiology b.Any patient with presumptive aseptic meningitis c. Guillain-Barre syndrome

23. Division of Public Health Services New Hampshire Department of Health and Human Services Criteria for Report Severe arboviral disease has occurred in patients of all ages. Consider patient travel history in off- season months. Year-round transmission is possible in some areas of the country.

24. Division of Public Health Services New Hampshire Department of Health and Human Services

25. Division of Public Health Services New Hampshire Department of Health and Human Services PREVENTION

26. Division of Public Health Services New Hampshire Department of Health and Human Services Personal Protection Works Wear long sleeves and pants in light colors to minimize the opportunities for mosquitoes to bite. Limit outside activity between evening and dawn when mosquitoes are most likely to bite. Consider using an effective insect repellent.

27. Division of Public Health Services New Hampshire Department of Health and Human Services

28. Division of Public Health Services New Hampshire Department of Health and Human Services Insect Repellents

29. Division of Public Health Services New Hampshire Department of Health and Human Services Mosquito Repellents: CDC Recommendations DEET - Used for >50 years, with millions of doses applied - Long-term safety established - In children: American Academy of Pediatrics affirms use of DEET (up to 30%) over 2 months of age

30. Division of Public Health Services New Hampshire Department of Health and Human Services Mosquito Repellents: CDC Recommendations Picaridin - Used for years in Australia and Europe - Concentration available in US less - No serious toxicity reported Oil of Lemon Eucalyptus - plant derived compound - No serious toxicity reported - Recommended for children >3 years

31. Division of Public Health Services New Hampshire Department of Health and Human Services The Bottom Line Repellent adverse reactions, when used appropriately are extremely rare EEE (and other mosquito-borne diseases) are definite, recognized threats to human health - Certain situations (risk factors for severe disease, outbreak situations) increase risk - Problems following arboviral neuroinvasive disease can be permanent

32. Division of Public Health Services New Hampshire Department of Health and Human Services Repellent Resources U.S. Environmental Protection Agency http://www.epa.gov/pesticides/health/ mosquitoes/insectrp.htm National Pesticide Information Center http://npic.orst.edu/wnv/

33. Division of Public Health Services New Hampshire Department of Health and Human Services The 2008 Season?

34. Division of Public Health Services New Hampshire Department of Health and Human Services 2008 Season? Unable to forecast the exact level of risk NH communities with prior year’s EEE activity should consider mosquito-borne illness to be a human health risk for 2008

35. Division of Public Health Services New Hampshire Department of Health and Human Services

36. Division of Public Health Services New Hampshire Department of Health and Human Services Questions?