The United States Centers for Disease Control (CDC) function as the national public health authority. Within the Centers is the Division of Vector Borne Infectious Diseases (DVBID). Its mission is to provide, at the national level, surveillance, research, diagnostic testing and assistance to state, local and foreign governments with regard to vector borne diseases. Those are illnesses carried by mosquitoes, ticks, fleas and other animals that can be transmitted to humans.

The budget for the DVBID in 2010 was $26.7 million. That line has been defunded in the Administration’s 2011 proposal, with $18.9 million added to the emerging infectious diseases area…

The American Society for Tropical Medicine and Hygiene (ASTMH) has called for restoration of the funding for DVBID. Edward T. Ryan, M.D., President of the ASTMH, spoke with me recently about this issue.

This is the division that works on dengue fever, malaria, Lyme disease, West Nile virus, spotted fever and all the other illnesses we get from bug bites.

More at Budget cuts at CDC threaten efforts on bug borne diseases

mosquito biting

[begin Rod Sterling narrative]
It was a typical summer morning for new high school graduate Mary Doe. She donned a robe from her closet and went down the hall to fix breakfast. Little did she suspect what would follow her out of that closet.

It followed her into the kitchen, with only one thing in mind. Her blood. Mary Doe was about to be the subject of a vicious attack. It wanted blood, her blood, to make its babies.

The babies would spread, throughout the house, the neighborhood and the city. Mary Doe’s blood would not be the first to be taken by these monsters.
[end Rod Sterling narrative]

If mosquito bites were a movie, that is how the movie would begin. Nearly everyone has experienced a mosquito bite, the raised bump, the unbearable itching. The story of mosquitoes and man is a complex tale of adaptation, co-existence and far too often, a deadly illness.

The United States, and upstate New York, are very familiar with both mosquitoes and the illnesses they may carry. The ease with which the world interconnects at this time is bringing some strangers to America, new breeds of mosquito and new illnesses.

Not all mosquitoes bite humans. Some bite both animals and humans. Some only bite humans. All biting mosquitoes have one thing in common, they’re female. The blood they draw when they bite allows them to reproduce. The illnesses, viral, bacterial and parasitic, that they ingest from sick people and carry to other people, are just incidentals to their main purpose. They want to make babies and they need our blood to do it.

WEST NILE VIRUS
Rochester and Upstate New York residents are familiar with the West Nile virus. It arrived in the United States about 1999, and was first discovered in New York City. While most people infected with the virus show no symptoms, those with symptoms suffer a flu-like illness for days or weeks. In less than one percent of those infected, life threatening forms of West Nile called West Nile encephalitis, West Nile meningitis or West Nile meningoencephalitis can develop.

This map reflects surveillance findings occurring between January 1, 2009 through December 31, 2009 as reported to CDC's ArboNET system for public distribution by state and local health departments.

West Nile is spread by various members of the Culex family of mosquitoes with Cx. Pipiens being the primary carrier in New York. It is also called the Northern House Mosquito.

Cx. Pipiens loves the filthy water around people. It breeds in storm drains and sewers, even raw sewage and at sewage treatment plants.

It feeds on birds, some mammals and on humans.

YELLOW FEVER
New York has not seen a local outbreak of yellow fever since about 1870. Before then, the illness was a regular visitor to New York City, Albany and other parts of the state.

The following partial list of outbreaks in New York State is from the World Health Organization publication Yellow Fever, published in 1998.

1694 in Boston, New York and Philadelphia

1702 in New York

1734 in New York, Boston, Charleston, Philadelphia and Albany,

1743 in New York and Virginia

1745 in New York and Charleston

1751 in New York and Philadelphia

1791 in New York and Philadelphia

New York in 1801, 1819, 1821, 1822, 1870

1870 New York The last recorded outbreak of yellow fever in New York

Aedes aegypti is the usual mosquito carrier of this illness. Currently it is found much farther south than New York, though its range varies with the weather.

Aedes aegypti has re-emerged in the Americas following a successful hemispheric eradication campaign during the 1950s and 1960s. CDC map

A. aegypti is very adapted to living around humans. It has regulated its wing speed to reduce the buzz or hum that humans identify with mosquitoes. It is a day feeder, choosing the early morning or late evening to feed. During the heat of the day these mosquitoes seek out dark hiding places where there is little air circulation, like closets or under tables. Most bites from A. aegypti are to the lower leg.

A. aegypti is the opposite of the Culex mosquitoes when it comes to breeding sites. It seeks clean water, rain gutters, clear pools and containers that have collected rain.

MALARIA
Malaria may be one of the earliest illnesses to be described. It is a deadly illness, killing about a million people worldwide every year. It was considered eliminated in the United States by 1951.

In New York, the malaria risk was along the waterways, New York City, up the Hudson River to Albany, along the Mohawk River west, the Lake Ontario and Lake Erie shorelines.

Distribution of Malaria in the United States and Canada in 1882 Reiter, Paul: Environmental Health Perspectives: Vol. 109 -suppl. 1-: Figure 4, Pg 149, March 2001.

Malaria is a parasite carried and transmitted to humans by mosquitoes in the genus Anopheles. An. quadrimaculatus is the variety common to the New York area.

Despite the eradication of malaria in the United States, cases are discovered every year. Most are acquired by travelers in regions of the world where malaria is prevalent. There are occasional outbreaks, such as this one in New Jersey in 1991, that appear to be native. It is almost certain, however, that the initial host was a traveler who did not know they were sick and was bitten by mosquitoes. This is a common source of outbreaks of mosquito borne illnesses not native to the United States.

An. quadrimaculatus inhabits the eastern United States, east of the Mississippi. They prefer freshwater pods, steams and lakes with vegetation. The mosquito prefers to take blood from animals. They are night feeders.

DENGUE FEVER
Dengue fever has hit the headlines after an outbreak or series of outbreaks of this tropical illness in Key West, Florida. The last outbreak of this illness native to the United States was in 1945, so its reemergence in 2009 was startling.

There have been dengue fever cases and outbreaks traced to travelers, including cases in Florida at this time. One traces to Puerto Rico, another to Haiti, both areas where dengue is endemic.

Dengue is carries by A. aegypti. This should mean that the outbreak can only move as far north as this mosquito can survive, perhaps into the Carolinas. However, a recent illegal immigrant to the United States may change that assumption.

Ae. albopictus, the Asian Tiger mosquito, was accidentally brought in to the United States in the 1980′s. This map shows its range in 2000, and it most certainly has spread in the decade since the map was created.

USDA map of the distribution of the Asian Tiger mosquito in the United States in 2000

Ae. albopictus is known to spread dengue fever, as well as eastern equine encephalomyelitis and the Cache Valley virus. It is also reported to be able to carry West Nile.

The Aedes genera of mosquitoes are highly adapted to living near humans. they have also demonstrated a high degree of adaptation to changing habitat. Their eggs may survive for several months in a dried out area and revive when water returns to the area.

In an interview this week, Dr. Roxanne Connelly, who is Associate Professor and Extension State Specialist of Medical Entomology at the University of Florida, talked about mosquitoes with me. Mosquitoes vary by genera and species and can vary within the species with regional differences. That may include the ability to act as a good carrier of disease microbes. The existence of a particular type of mosquito in a region does not necessarily mean that an outbreak of illness is possible.

Dr. Connelly told me that the primary mosquito borne illness to be aware of in Western New York would be West Nile. She did suggest that a local outbreak of any tropical illness can occur if a sick traveler is bitten enough to create a pool of infection in the local mosquito population.

In an e-mail, Dr. Laura Harrington, Associate Professor, Department of Entomology at Cornell University, talked about the Asian Tiger mosquito, Ae. albopictus. She has found these mosquitoes in New York and New York City but they are not yet able to survive year round. This summer, she is working with others to identify the adaptations made by those Ae. albopictus that are now year round in New Jersey. She believes that any migration into New York by this mosquito would most likely come from the variety now living in New Jersey.

Dr. Harrington closed her e-mail with the suggestion that Rift Valley Fever could have a great impact on both humans and animals in New York should it be introduced. She states that we now have more than one mosquito capable of transmitting that illness.

Mr. Simba Mobagi, a lab technician with Kenya’s Rachuonyo district hospital, works with U.S. Army Maj. Eric Wagar to accurately diagnose malaria in blood samples. - U.S. Army photo by Rick Scavetta.

Inside Rachuonyo district hospital, Simba Mobagi peers through his laboratory’s only microscope at a sick woman’s blood sample.

The 33-year-old laboratory technologist’s goal – rapidly identifying malaria parasites.
Dozens more samples await his eyes. Each represents a patient suffering outside on wooden benches.

Mogabi takes little time to ponder his workload. He quickly finds malaria parasites, marks his findings on a pink patient record and moves to the next slide. Much to his surprise, a U.S. Army officer arrives, removes his black beret and sets down a large box.

Inside Maj. Eric Wagar’s box is a new microscope – a small gesture within U.S. Army Medical Research Unit-Kenya’s larger efforts to improve malaria diagnostics in Africa.

For more than 40 years, USAMRU-K – known locally as the Walter Reed Project – has studied diseases in East Africa through a partnership with the Kenya Medical Research Institute.

Wagar heads USAMRU-K’s Malaria Diagnostics and Control Center of Excellence in Kisumu, a unique establishment begun in 2004 that’s since trained more than 650 laboratory specialist to better their malaria microscopy skills.

“Working with the Walter Reed Project is so good for the community, as it benefits the patient,” Mobagi said, who is looking forward to attending the center’s malaria diagnostics course. “Plus, having a new microscope improves our work environment. Work will be easier and we will have better outcomes.”

Back in Kisumu, wall maps mark the center’s success, with hundreds of trained lab technicians from more than a dozen countries across the African continent. International students have come from Ireland, the U.S. and Thailand.

Many students are sponsored through U.S. government aid programs aimed at reducing disease in Africa or by nongovernmental organizations. Most of the center’s $450,000 annual budget comes from the U.S. President’s Malaria Initiative. Other funding is from the U.S. Defense Department, NGOs and pharmaceutical companies.

For students to practice malaria identification, five Kenyan lab technicians work tirelessly to create a variety of blood specimens. Slides may show one or more of malaria’s several species – others are free of parasites. The majority of malaria cases are the falciparum species, but many people are co-infected with other species and it’s important for students to recognize that, Wagar said.

“At our course, lab students learn skills and habits that increase their ability to accurately detect malaria on blood slides. Yet, when they return to their local laboratories, they face the challenge of changing habits and procedures,” Wagar said. “Changing behavior is hard to do.”

In late-April, Wagar accompanied Jew Ochola, 28, the center’s daily operations manager to Oyugis, the district center of Rachuonyo that lies roughly 30 miles south of Kisumu in Kenya’s Nyanza province.

“First I do an assessment of the hospital’s lab, what procedures they have, the number of people on staff and the equipment they use,” Ochola said. “By partnering with laboratory managers, we hope to increase standards and improve efficient and effective diagnosis.

The goal is to lessen the burden of malaria on the local people.”

To mark progress, lab staffs must collect 20 slides each month that show properly handled blood samples. Monthly visits will mark performance improvement.

Through quality malaria diagnosis, USAMRU-K is part of a larger public health effort to reduce malaria’s impacts on Kenyan’s lives. Illness means paying for treatment and less wages earned, creating an impact on the economy.

“By mitigating a public health burden, people should have more time to grow food and have money for things other than medical care,” Wagar said. “We can’t expect to see change right away, but hopefully things will be a little bit better every month.”

Working with the Djibouti-based Combined Joint Task Force – Horn of Africa and other DoD agencies, the center recently offered microscopy courses through U.S. military partnership events in Ghana, Nigeria and Tanzania. The effort supports U.S. Army Africa’s strategic engagement goal of increasing capabilities and strengthening capacity with the militaries of African nations, Wagar said.

“To date, that includes eight Kenyan military lab techs, 17 from the Tanzania People’s Defense Force and 30 Nigerians,” Wagar said.

Accurate diagnosis is also a key factor for military readiness, Wagar said. For example, a Kenyan soldier stationed in Nairobi – where malaria is less prevalent – is susceptible to the disease if posted elsewhere in the country.

“Improving malaria diagnosis within African military laboratories sets conditions for healthier troops,” Wagar said. “When forces are healthy, they are more capable to support their government and regional security.”

US Army Africa
By Rick Scavetta

The Army has been fighting malaria forever. Some of the greatest achievements in public health were made possible by U.S. Army doctors such as Walter Reed.

U.S. Navy Petty Officer 2nd Class Mathew Colson (middle) with APS West platform USS Gunston Hall observes as Senegalese Army Pvt. Cheikh Amanga (right) practices giving an intravenous catheter on Senegalese Army Pvt. Senghane Mbodj (left) during a tactical combat casualty care training course at the Ouakam Military Hospital for 26 members of the Senegalese Armed Forces as part of Africa Partnership Station West 2010 initiative. APS an international initiative developed by Naval Forces Europe - Africa, which aims to work cooperatively with U.S. and international partners to improve maritime safety and security in Africa.

Researchers at the Walter Reed Army Institute of Research here are discovering new ways to combat and prevent the spread of malaria.

“Every conflict the U.S. has been in we’ve been faced with malaria,” said Army Col. Christian Ockenhouse, director of the U.S. Military Malaria Vaccine Program, during an April 14 interview on the Pentagon Channel podcast “Armed with Science: Research and Applications for the Modern Military.

Malaria is a parasitic disease which infects red blood cells, Ockenhouse said. It’s transmitted through the bite of a female mosquito, goes to the liver to develop and emerges after five days into the bloodstream to cause the disease.

Most people believe malaria is a disease of the past, but it has not disappeared, he said. In sub-Saharan Africa, 3,000 children die every day from the disease, he noted, which also can target adults, including U.S. troops serving in Afghanistan, South America and Africa.

More information about malaria:

• Info 101: Malaria
• Malaria is not gone, just forgotten

In the military, malaria impacts readiness and missions, and measures are implemented to combat the disease, Ockenhouse said. Using insect repellant and camouflage face paint with repellent in it, wearing uniforms impregnated with insecticides and employing bed nets can help to prevent malaria.

One of the important measures to prevent the disease is taking anti-malaria pills. This pill regime is one of the most effective preventative methods, Ockenhouse said, but it has to be performed daily. “Often time soldiers forget or don’t take it if they don’t see any symptoms,” he said.

The researchers are working with the U.S. Food and Drug Administration in three areas to protect service members and children against malaria. First, they are developing a highly safe, highly effective vaccine. A second area is to develop better diagnostics, which would allow earlier detection and treatment of the malaria parasite in the blood. Third, they are developing new anti-malarial drugs to prevent infection and treat those that have it.

The researchers also are developing a medication for severe malaria. Ockenhouse spoke of an in-house program designed not only for early-stage research and development, but also to test new drugs against malaria in late-stage clinical trials intended for FDA approval.

The group also works overseas with laboratories located in Kenya, Thailand, Tanzania, Mali, South America and Peru.

“We are ambassadors in the countries where we work. We are there to lend assistance to their public health initiatives, which includes helping these countries test malaria vaccines, drugs and diagnostics and aiding in infrastructure and capacity development.”

The researchers also have assisted in the development of the world’s most advanced malaria vaccine that is being tested in 16,000 infants in 11 different countries. Preliminary studies indicate that use of the vaccine can reduce malaria by 50 percent. When licensed and made available the vaccine could save hundreds of thousands, if not millions, of children’s lives, Ockenhouse said.

“We are at the forefront of many endeavors in drugs and vaccines,” Ockenhouse said. “The DoD should be particularly proud that it is stepping up to the plate and leading the world’s efforts on this disease.”

DVIDS
Story by Christen McCluney

A hospital corpsman with the 2nd Marine Expeditionary Brigade teaches a Marine how to insert a needle into a vein as part of a Combat Lifesaver Course here March 24. Marines gain this knowledge so they can support corpsmen in the field in need of assistance. Photo by Cpl. Aaron Rooks

Combating insurgency in Afghanistan is not the only challenge awaiting the Marines and sailors of the 2nd Marine Expeditionary Brigade.

In addition to enemy combatants, Marines deploying to Afghanistan’s Regional Command-South will also face a number of potential health threats.

The Central Asian country has been labeled by the World Health Organization as one of the least developed countries in the world, with 70 percent of the population living in extreme poverty and health vulnerability.

Several food-, water-, animal-, and vector-borne diseases are found commonly throughout the country. The most common of all, according to Afghanistan’s Ministry of Public Health, is malaria.

More than half of the country’s population, especially women and children, are vulnerable to malaria, according to an April 2008 report from the Integrated Regional Information Networks, the humanitarian news and analysis service of the United Nations Office for the Coordination of Humanitarian Affairs.

The Ministry of Public Health and WHO estimated that up to 1.5 million cases of malaria occur each year throughout Afghanistan, most of which go untreated.

The 2nd MEB Health Services Support Section identified malaria, bacterial and protozoal diarrhea, hepatitis A, rabies, typhoid and paratyphoid fever as the diseases of highest risk in Regional Command-South. The medical staff has also identified tuberculosis, hepatitis E, sand fly fever, typhus, leishmaniasis, west nile fever and anthrax as some of the intermediate risks present in the Marines’ future area of operations.

Navy Petty Officer 3rd Class Matthew Siruchek, a hospital corpsman with 2nd MEB, said preventive medicine is key for Marines and sailors deploying to the region.

The Walden, N.Y., native, who deployed to Afghanistan with the 24th Marine Expeditionary Unit from March to October 2008, said malaria was their largest concern.

“Preventive treatment and education made the difference,” he said. “We always preached to them to take their medications once a week and they would be covered.”

Medication includes Mefloquine, a treatment used to combat malaria, which is transmitted primarily by mosquitoes.

The HSSS is taking these precautions and others. Navy Senior Chief Petty Officer Shannon Dittlinger, medical operations chief for the HSSS, said her team of corpsmen and Navy doctors has worked diligently since February to ensure the brigade is medically ready.

The Weirsdale, Fla., native said they have sprayed uniforms and sleeping systems to deter disease-carrying insects, ordered the necessary medications and conducted health, dental and neurological assessments. They have also performed vaccinations to prevent diseases such as yellow fever, anthrax, smallpox, hepatitis A, typhoid and measles.

But Navy Petty Officer 2nd Class Jose Gonzalezramos, a hospital corpsman and preventive medicine technician for the brigade, said there’s no preventive medicine offered for Marines to combat some of the diseases found in Afghanistan.

The Maunavo, Puerto Rico native said education plays the largest role in combating these diseases and other medical conditions overseas.

“If Marines listen to what we recommend to them, they will be healthier,” he said. “If there is a shot that can prevent you from contracting diseases, why not get it? If you know a water source is contaminated, why go near it? If Marines or sailors contract any of these diseases, they will be taken out of the fight temporarily or permanently.”

The HSSS team members said they are prepared in case anyone contracts one of the many diseases in the country, which the brigade medical planner, Navy Lt. Diana Loffgren, said is possible. She said there are currently several confirmed cases of malaria in troops serving in Afghanistan, but noted that none of these cases involve U.S. service members.

Despite the threats, the MEB medical personnel remain confident in the deployment being a success.

“I’m 100 percent confident in the corpsmen and doctors who will be taking care of the brigade’s medical issues, whether they are combat casualties or diseases,” Dittlinger said.

USMC
by Cpl. Aaron Rooks