- Email: [email protected]
Zika virus infection and microcephaly in Vietnam
Correspondence
the lives of tens of millions of people worldwide. Therefore, resistance to insecticides is more important and urgent risk than antibiotic resistance and global warming. Caution should be exercised around insecticidedenigrating campaigns, since the effects of insecticides on human beings remain to be proved. We declare no competing interests.
*Didier Raoult, Cédric Abat [email protected] URMITE UM 63 CNRS 7278 IRD 198 INSERM U1905, IHU Méditerranée Infection, Faculté de Médecine et de Pharmacie, Aix-Marseille Université, 13385 Marseille CEDEX 05, France (DR, CA) 1 2
3
4
5
Burki T. WHO Director-General shortlist chosen. Lancet Infect Dis 2017; 17: 267–68. Durand R, Bouvresse S, Berdjane Z, Izri A, Chosidow O, Clark JM. Insecticide resistance in head lice: clinical, parasitological and genetic aspects. Clin Microbiol Infect 2012; 18: 338–44. Sangare AK, Boutellis A, Drali R, et al. Detection of Bartonella quintana in African body and head lice. Am J Trop Med Hyg 2014; 91: 294–301. GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1459–544. Enserink M, Hines PJ, Vignieri SN, Wigginton NS, Yeston JS. The pesticide paradox. Science 2013; 341: 728–29.
Zika virus infection and microcephaly in Vietnam We read with great concern of the recent Zika virus outbreak in Singapore as reported by the Singapore Zika Study Group. 1 Although Zika virus infection has been previously associated with congenital malformations and neurological syndromes, 2,3 no antenatal or postnatal abnormalities were detected in pregnant women during the Singapore outbreak. 1 The spectrum of disease associated with vertical Zika virus infection in the region remains unclear, and considering the rapidly expanding www.thelancet.com/infection Vol 17 August 2017
Zika virus epidemic in Asia, further detailed assessment is urgently needed. As of March 1, 2017, 23 laboratoryconfirmed cases of Zika virus infection had been identified in Vietnam. Before reports of exported Zika virus cases in December, 2015, no cases had been reported in Vietnam. 4 Following the detection of local cases of Zika virus infection in March, 2016, local authorities intensified Zika virus disease surveillance and control measures. During the outbreak, on June, 2016, a girl was born with microcephaly in Dak Lak Province, in the Central Highlands region of Vietnam, at 37 weeks of gestation (figure). The infant’s mother (aged 23 years) had experienced symptoms of fever and rash associated with Zika virus infection during her second trimester. The symptoms resolved uneventfully. When the child was 3–4 months of age, the child, mother, and four intermediate family members (father, grandmother, uncle, and an adopted child) had high concentrations of Zika virus-specific neutralising antibody (the serum titre required to reduce viral plaques by 50% [PRNT 50] was 1/160–1/1280; appendix), confirming recent viral exposure. Both the mother and child did not have a recent history of travel. Of the 17 people that the mother or child had come into contact with or who were neighbours, two were seropositive for Zika virus, suggesting a recent local outbreak in the area. Toxoplasmosis, rubella, cytomegalovirus, herpes simplex, dengue, and Japanese encephalitis were ruled out in both the mother and child, following local and WHO guidelines.5 Follow-up examinations were done at ages 4 and 9 months. CT images of the child’s brain showed multiple isolated foci of calcification of the frontal and parietal lobes, and ventriculomegaly with decreased brain volume at age 4 months (appendix). The CT findings were
Figure: Facial features of a child aged 4 months exposed to Zika virus in Vietnam The infant was born by spontaneous vaginal delivery (bodyweight 2·6 kg; length 50 cm; head circumference 22 cm at birth).
consistent with those of children with vertical Zika virus infection in the Americas. 2 At age 9 months, the infant showed psychomotor developmental delays, with generalised spastic dystonia and cerebral palsy. She also reacted poorly to external stimulation and showed fixed, dilated pupils upon examination, suggesting ocular manifestations. The spectrum of the congenital Zika virus syndrome and epidemiology in Asia remains undefined. We thus advocate further efforts to determine the extent of Zika virus vertical infection in the region to gain a better understanding of the risks of congenital Zika virus syndrome in different parts of the world.
See Online for appendix
We declare no competing interests. We thank the health-care practitioners of the clinics and hospitals in Vietnam who supported the study. We thank Phu Ly Minh Huong and Satoshi Shimada for helpful discussion. We also thank Shashika Lavangi Wijesooriya for technical assistance. This work was supported by grants from the Japan Initiative for Global Research Network on Infectious Diseases (JGRID) and the Research Program on Emerging and Re-emerging Infectious Diseases of the Japan Agency for Medical Research and Development (AMED); e-Asia Joint Research Program (e-Asia JRP) of the Japan Science and Technology Agency (JST); and MSD Life Science Foundation International. The ethics committee of
805
Correspondence
the Institute of Tropical Medicine, Nagasaki University, Japan (08061924–7) and National Institute of Hygiene and Epidemiology, Hanoi, Vietnam (IRB-VN01057/2016) approved the study.
Meng Ling Moi, Thi Thu Thuy Nguyen, Co Thach Nguyen, Thi Bich Hau Vu, Mya Myat Ngwe Tun, Tho Duoc Pham, Ngoc Thanh Pham, Thuan Tran, Kouichi Morita, Thi Quynh Mai Le, Duc Anh Dang, *Futoshi Hasebe [email protected]
See Online for appendix
WHO Collaborating Centre for Reference and Research on Tropical and Emerging Virus Diseases, Institute of Tropical Medicine, Nagasaki University, Nagasaki 852-8523, Japan (MLM, MMNT, KM, FH); National Institute of Hygiene and Epidemiology, Hanoi, Vietnam (TTTN, CTN, TBHV, TQML, DAD); Institute of Hygiene and Epidemiology of Tay Nguyen, Dak Lak, Vietnam (TDP, NTP); and Preventive Medicine Center, Krong Buk District, Vietnam (TT) 1
2
3
4 5
The Singapore Zika Study Group. Outbreak of Zika virus infection in Singapore: an epidemiological, entomological, virological and clinical analysis. Lancet Infect Dis 2017; published online May 17. http://dx.doi. org/10·1016/S1473–3099(17)30249–9. Hazin AN, Poretti A, Di Cavalcanti Souza Cruz D, et al. Computed tomographic findings in microcephaly associated with Zika virus. N Engl J Med 2016; 374: 2193–95. Cao-Lormeau VM, Blake A, Mons S, et al. Guillain-Barré Syndrome outbreak associated with Zika virus infection in French Polynesia: a case-control study. Lancet 2016; 387: 1531–39. Duong V, Dussart P, Buchny P. Zika virus in Asia. Int J Infect Dis 2017; 54: 121–28. Oladapo OT, Souza JP, De Mucio B, de León RG, et al. WHO interim guidance on pregnancy management in the context of Zika virus infection. Lancet Glob Health 2016; 4: e510–11.
Surveillance of Crimean-Congo haemorrhagic fever in Pakistan Crimean-Congo haemorrhagic fever (CCHF) is a tick-borne viral disease that has been reported across Asia, Africa, eastern Europe, the Balkans, and the Middle East. In Pakistan, the first case of CCHF was documented in 1976 and its prevalence has been vigorously debated since.1 Findings from some studies have associated the incidence of CCHF in Pakistan with the coinciding event of Eid806
ul-Adha, when tens of millions of animals are sacrificed every year.1,2 Although epidemiological evidence3 suggests that animal movement during Eid-ul-Adha might facilitate the transmission of CCHF virus, the extent of the facilitation is not well known. We plotted the time of Eidul-Adha against the onset date of cases of CCHF confirmed by real-time PCR assay at the National Institute of Health (NIH), Islamabad, Pakistan (appendix). Our analysis, based on 1339 suspected cases, 302 (23%) of which were laboratory confirmed, during January 2011 to March 2017, did not show a direct association between the occurrence of CCHF cases and the time of Eid-ul-Adha, thus rebuking the earlier notions. In fact, the exceedingly abundant prevalence of hyalomma ticks in Pakistan, largely during the summer months, is well documented, 4 thus substantiating our findings that the CCHF cases in Pakistan might appear independently of Eid-ul-Adha, and their occurrence has coincided with the peak season of tick proliferation during the preceding 8–10 years. Previous reports1,2 have attributed the enhanced CCHF spread to the movement of animals from Balochistan, but no concrete evidence is available ratifying this explanation as the sole contributor to sporadic CCHF cases outside Balochistan. In support, we refer to our findings5–7 that the CCHFV virus strains are endemic and strictly restricted within Balochistan where cases continue to be reported throughout the year with incidental spillovers elsewhere in the country. These findings are further reinforced by our data showing 99–100% genetic relatedness among the CCHF viral strains detected in Balochistan over decades, 6 thus signifying that Balochistan might have an isolated and dispersed population of CCHF-virus hosts and a vector that might sustain and amplify the disease primarily within the province.
NIH-Pakistan is the focal point for International Health Regulations and the country’s only reference public health laboratory, providing freeof-cost diagnostic services for many high-priority diseases including CCHF. Nevertheless, there is a dire need to enhance coordination between animal and human sectors through integrated disease surveillance to foster preparedness and effective prevention and control. We declare no competing interests.
*Muhammad Masroor Alam, Adnan Khurshid, Muhammad Suleman Rana, Uzma Bashir Aamir, Muhammad Salman, Mukhtar Ahmad [email protected] Department of Virology, National Institute of Health, Chak Shahzad, Islamabad, Pakistan (MMA, AK, MSR, UBA, MS, MA) 1
2
3
4
5
6
7
Karim AM, Hussain I, Lee JH, Park KS, Lee SH. Surveillance of Crimean-Congo haemorrhagic fever in Pakistan. Lancet Infect Dis 2017; 17: 367–68. Mallhi TH, Khan YH, Sarriff A, Khan AH. Crimean-Congo haemorrhagic fever virus and Eid-Ul-Adha festival in Pakistan. Lancet Infect Dis 2016; 16: 1332–33. Al-Abri SS, Abaidani IA, Fazlalipour M, et al. Current status of Crimean-Congo haemorrhagic fever in the World Health Organization Eastern Mediterranean Region: issues, challenges, and future directions. Int J Infect Dis 2017; 58: 82–89. Sajid MS, Iqbal Z, Khan MN, Muhammad G. Point prevalence of hard ticks (Ixodids) infesting domestic ruminants of lower Punjab, Pakistan. Int J Agri Biol 2008; 10: 349–51. Alam MM, Kurshid A, Sharif S, et al. Crimean-Congo hemorrhagic fever Asia-2 genotype, Pakistan. Emerg Infect Dis 2013; 19: 1017–19. Alam MM, Khurshid A, Sharif S, et al. Genetic analysis and epidemiology of Crimean Congo hemorrhagic fever viruses in Baluchistan province of Pakistan. BMC Infect Dis 2013; 13: 201. Khurshid A, Hassan M, Alam MM, et al. CCHF virus variants in Pakistan and Afghanistan: Emerging diversity and epidemiology. J Clin Virol 2015; 67: 25–30.
www.thelancet.com/infection Vol 17 August 2017
the lives of tens of millions of people worldwide. Therefore, resistance to insecticides is more important and urgent risk than antibiotic resistance and global warming. Caution should be exercised around insecticidedenigrating campaigns, since the effects of insecticides on human beings remain to be proved. We declare no competing interests.
*Didier Raoult, Cédric Abat [email protected] URMITE UM 63 CNRS 7278 IRD 198 INSERM U1905, IHU Méditerranée Infection, Faculté de Médecine et de Pharmacie, Aix-Marseille Université, 13385 Marseille CEDEX 05, France (DR, CA) 1 2
3
4
5
Burki T. WHO Director-General shortlist chosen. Lancet Infect Dis 2017; 17: 267–68. Durand R, Bouvresse S, Berdjane Z, Izri A, Chosidow O, Clark JM. Insecticide resistance in head lice: clinical, parasitological and genetic aspects. Clin Microbiol Infect 2012; 18: 338–44. Sangare AK, Boutellis A, Drali R, et al. Detection of Bartonella quintana in African body and head lice. Am J Trop Med Hyg 2014; 91: 294–301. GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1459–544. Enserink M, Hines PJ, Vignieri SN, Wigginton NS, Yeston JS. The pesticide paradox. Science 2013; 341: 728–29.
Zika virus infection and microcephaly in Vietnam We read with great concern of the recent Zika virus outbreak in Singapore as reported by the Singapore Zika Study Group. 1 Although Zika virus infection has been previously associated with congenital malformations and neurological syndromes, 2,3 no antenatal or postnatal abnormalities were detected in pregnant women during the Singapore outbreak. 1 The spectrum of disease associated with vertical Zika virus infection in the region remains unclear, and considering the rapidly expanding www.thelancet.com/infection Vol 17 August 2017
Zika virus epidemic in Asia, further detailed assessment is urgently needed. As of March 1, 2017, 23 laboratoryconfirmed cases of Zika virus infection had been identified in Vietnam. Before reports of exported Zika virus cases in December, 2015, no cases had been reported in Vietnam. 4 Following the detection of local cases of Zika virus infection in March, 2016, local authorities intensified Zika virus disease surveillance and control measures. During the outbreak, on June, 2016, a girl was born with microcephaly in Dak Lak Province, in the Central Highlands region of Vietnam, at 37 weeks of gestation (figure). The infant’s mother (aged 23 years) had experienced symptoms of fever and rash associated with Zika virus infection during her second trimester. The symptoms resolved uneventfully. When the child was 3–4 months of age, the child, mother, and four intermediate family members (father, grandmother, uncle, and an adopted child) had high concentrations of Zika virus-specific neutralising antibody (the serum titre required to reduce viral plaques by 50% [PRNT 50] was 1/160–1/1280; appendix), confirming recent viral exposure. Both the mother and child did not have a recent history of travel. Of the 17 people that the mother or child had come into contact with or who were neighbours, two were seropositive for Zika virus, suggesting a recent local outbreak in the area. Toxoplasmosis, rubella, cytomegalovirus, herpes simplex, dengue, and Japanese encephalitis were ruled out in both the mother and child, following local and WHO guidelines.5 Follow-up examinations were done at ages 4 and 9 months. CT images of the child’s brain showed multiple isolated foci of calcification of the frontal and parietal lobes, and ventriculomegaly with decreased brain volume at age 4 months (appendix). The CT findings were
Figure: Facial features of a child aged 4 months exposed to Zika virus in Vietnam The infant was born by spontaneous vaginal delivery (bodyweight 2·6 kg; length 50 cm; head circumference 22 cm at birth).
consistent with those of children with vertical Zika virus infection in the Americas. 2 At age 9 months, the infant showed psychomotor developmental delays, with generalised spastic dystonia and cerebral palsy. She also reacted poorly to external stimulation and showed fixed, dilated pupils upon examination, suggesting ocular manifestations. The spectrum of the congenital Zika virus syndrome and epidemiology in Asia remains undefined. We thus advocate further efforts to determine the extent of Zika virus vertical infection in the region to gain a better understanding of the risks of congenital Zika virus syndrome in different parts of the world.
See Online for appendix
We declare no competing interests. We thank the health-care practitioners of the clinics and hospitals in Vietnam who supported the study. We thank Phu Ly Minh Huong and Satoshi Shimada for helpful discussion. We also thank Shashika Lavangi Wijesooriya for technical assistance. This work was supported by grants from the Japan Initiative for Global Research Network on Infectious Diseases (JGRID) and the Research Program on Emerging and Re-emerging Infectious Diseases of the Japan Agency for Medical Research and Development (AMED); e-Asia Joint Research Program (e-Asia JRP) of the Japan Science and Technology Agency (JST); and MSD Life Science Foundation International. The ethics committee of
805
Correspondence
the Institute of Tropical Medicine, Nagasaki University, Japan (08061924–7) and National Institute of Hygiene and Epidemiology, Hanoi, Vietnam (IRB-VN01057/2016) approved the study.
Meng Ling Moi, Thi Thu Thuy Nguyen, Co Thach Nguyen, Thi Bich Hau Vu, Mya Myat Ngwe Tun, Tho Duoc Pham, Ngoc Thanh Pham, Thuan Tran, Kouichi Morita, Thi Quynh Mai Le, Duc Anh Dang, *Futoshi Hasebe [email protected]
See Online for appendix
WHO Collaborating Centre for Reference and Research on Tropical and Emerging Virus Diseases, Institute of Tropical Medicine, Nagasaki University, Nagasaki 852-8523, Japan (MLM, MMNT, KM, FH); National Institute of Hygiene and Epidemiology, Hanoi, Vietnam (TTTN, CTN, TBHV, TQML, DAD); Institute of Hygiene and Epidemiology of Tay Nguyen, Dak Lak, Vietnam (TDP, NTP); and Preventive Medicine Center, Krong Buk District, Vietnam (TT) 1
2
3
4 5
The Singapore Zika Study Group. Outbreak of Zika virus infection in Singapore: an epidemiological, entomological, virological and clinical analysis. Lancet Infect Dis 2017; published online May 17. http://dx.doi. org/10·1016/S1473–3099(17)30249–9. Hazin AN, Poretti A, Di Cavalcanti Souza Cruz D, et al. Computed tomographic findings in microcephaly associated with Zika virus. N Engl J Med 2016; 374: 2193–95. Cao-Lormeau VM, Blake A, Mons S, et al. Guillain-Barré Syndrome outbreak associated with Zika virus infection in French Polynesia: a case-control study. Lancet 2016; 387: 1531–39. Duong V, Dussart P, Buchny P. Zika virus in Asia. Int J Infect Dis 2017; 54: 121–28. Oladapo OT, Souza JP, De Mucio B, de León RG, et al. WHO interim guidance on pregnancy management in the context of Zika virus infection. Lancet Glob Health 2016; 4: e510–11.
Surveillance of Crimean-Congo haemorrhagic fever in Pakistan Crimean-Congo haemorrhagic fever (CCHF) is a tick-borne viral disease that has been reported across Asia, Africa, eastern Europe, the Balkans, and the Middle East. In Pakistan, the first case of CCHF was documented in 1976 and its prevalence has been vigorously debated since.1 Findings from some studies have associated the incidence of CCHF in Pakistan with the coinciding event of Eid806
ul-Adha, when tens of millions of animals are sacrificed every year.1,2 Although epidemiological evidence3 suggests that animal movement during Eid-ul-Adha might facilitate the transmission of CCHF virus, the extent of the facilitation is not well known. We plotted the time of Eidul-Adha against the onset date of cases of CCHF confirmed by real-time PCR assay at the National Institute of Health (NIH), Islamabad, Pakistan (appendix). Our analysis, based on 1339 suspected cases, 302 (23%) of which were laboratory confirmed, during January 2011 to March 2017, did not show a direct association between the occurrence of CCHF cases and the time of Eid-ul-Adha, thus rebuking the earlier notions. In fact, the exceedingly abundant prevalence of hyalomma ticks in Pakistan, largely during the summer months, is well documented, 4 thus substantiating our findings that the CCHF cases in Pakistan might appear independently of Eid-ul-Adha, and their occurrence has coincided with the peak season of tick proliferation during the preceding 8–10 years. Previous reports1,2 have attributed the enhanced CCHF spread to the movement of animals from Balochistan, but no concrete evidence is available ratifying this explanation as the sole contributor to sporadic CCHF cases outside Balochistan. In support, we refer to our findings5–7 that the CCHFV virus strains are endemic and strictly restricted within Balochistan where cases continue to be reported throughout the year with incidental spillovers elsewhere in the country. These findings are further reinforced by our data showing 99–100% genetic relatedness among the CCHF viral strains detected in Balochistan over decades, 6 thus signifying that Balochistan might have an isolated and dispersed population of CCHF-virus hosts and a vector that might sustain and amplify the disease primarily within the province.
NIH-Pakistan is the focal point for International Health Regulations and the country’s only reference public health laboratory, providing freeof-cost diagnostic services for many high-priority diseases including CCHF. Nevertheless, there is a dire need to enhance coordination between animal and human sectors through integrated disease surveillance to foster preparedness and effective prevention and control. We declare no competing interests.
*Muhammad Masroor Alam, Adnan Khurshid, Muhammad Suleman Rana, Uzma Bashir Aamir, Muhammad Salman, Mukhtar Ahmad [email protected] Department of Virology, National Institute of Health, Chak Shahzad, Islamabad, Pakistan (MMA, AK, MSR, UBA, MS, MA) 1
2
3
4
5
6
7
Karim AM, Hussain I, Lee JH, Park KS, Lee SH. Surveillance of Crimean-Congo haemorrhagic fever in Pakistan. Lancet Infect Dis 2017; 17: 367–68. Mallhi TH, Khan YH, Sarriff A, Khan AH. Crimean-Congo haemorrhagic fever virus and Eid-Ul-Adha festival in Pakistan. Lancet Infect Dis 2016; 16: 1332–33. Al-Abri SS, Abaidani IA, Fazlalipour M, et al. Current status of Crimean-Congo haemorrhagic fever in the World Health Organization Eastern Mediterranean Region: issues, challenges, and future directions. Int J Infect Dis 2017; 58: 82–89. Sajid MS, Iqbal Z, Khan MN, Muhammad G. Point prevalence of hard ticks (Ixodids) infesting domestic ruminants of lower Punjab, Pakistan. Int J Agri Biol 2008; 10: 349–51. Alam MM, Kurshid A, Sharif S, et al. Crimean-Congo hemorrhagic fever Asia-2 genotype, Pakistan. Emerg Infect Dis 2013; 19: 1017–19. Alam MM, Khurshid A, Sharif S, et al. Genetic analysis and epidemiology of Crimean Congo hemorrhagic fever viruses in Baluchistan province of Pakistan. BMC Infect Dis 2013; 13: 201. Khurshid A, Hassan M, Alam MM, et al. CCHF virus variants in Pakistan and Afghanistan: Emerging diversity and epidemiology. J Clin Virol 2015; 67: 25–30.
www.thelancet.com/infection Vol 17 August 2017