Transmission of West Nile virus in the Niagara Region among a population at risk for exposure

Background. West Nile Virus (WNV), a mosquito-borne flavivirus, is one of an increasing number of infectious diseases that have been emerging or re-emerging in the last two decades. Since the arrival ofWNV to Canada to present date, the Niagara Region has only reported 30 clinical cases, a small number compared to the hundreds reported in other regions of similar conditions. Moreover, the last reported human case in Niagara was in 2006. As it has been demonstrated that the majority of WNV infections are asymptomatic, the question remains whether the lack of clinical cases in Niagara truly reflects the lack of transmission to humans or if infections are still occurring but are mostly asymptomatic. Objectives. The general objective of this study was to establish whether or not active WNV transmission could be detected in a human population residing in Niagara for the 2007 transmission season. To fullfil this objective, a cross-sectional seroprevalence study was designed to investigate for the presence of anti-WNV antibodies in a sample of Mexican migrant agricultural workers employed in farms registered with the Seasonal Agricultural Workers Program (SAWP). Due to the Mexican origin of the study participants, three specific research objectives were proposed: a) determine the seroprevalence ofanti-WNV antibodies as well as anti-Dengue virus antibodies (a closely related virus prevalent in Mexico and likely to confound WNV serology); b) analyze risk factors associated with WNV and Dengue virus seropositivity; and c) assess the awareness of study participants about WNV infection as well as their understanding of the mode of transmission and clinical importance of the infection. Methodology: After obtaining ethics clearance from Brock University, farms were visited and workers invited to participate. Due to time constraints, only a small number of farms were enrolled with a resulting convenience and non-randomized study sample. Workers' demographic and epidemiological data were collected using a standardized questionnaire and blood samples were drawn to determine serum anti-WNV and anti- Dengue antibodies with a commercial ELISA. All positive samples were sent to the National Microbiology Laboratory in Winnipeg, Manitoba for confirmation with the Plaque Reduction Neutralization Test (PRNT). Data was analyzed with Stata 10.0. Antibody determinations were reported as seroprevalence proportions for both WNV and Dengue. Logistic regression was used to analyze risk factors that may be associated with seropositivity and awareness was reported as a proportion of the number of individuals possessing awareness over the total number of participants. Results and Discussion. In total 92 participants working in 5 farms completed the study. Using the commercial ELISA, seropositivity was as follows: 2.2% for WNV IgM, 20.7% for WNV IgG, and 17.1 % for Dengue IgG. Possible cross-reactivity was demonstrated in 15/20 (75.0%) samples that were positive for both WNV IgG and Dengue IgG. Confirmatory testing with the PRNT demonstrated that none of the WNV ELISA positive samples had antibodies to WNV but 13 samples tested positive for anti-Dengue antibodies (14.1 % Dengue sereoprevalence). The findings showed that the ELISA performance was very poor for assessing anti-WNV antibodies in individuals previously exposed to Dengue virus. However, the ELISA had better sensitivity and specificity for assessing anti-Dengue antibodies. Whereas statistical analysis could not be done for WNV seropositivity, as all samples were PRNT negative, logistic regression demonstrated several risk factors for Dengue exposure_ The first year coming to Canada appeared to be significantly associated with increased exposure to Dengue while lower socio-economic housing and the presence of a water basin in the yard in Mexico appeared to be significantly associated with a decreased exposure to Dengue_ These seemingly contradictory results illustrate that in mobile populations such as migrant workers, risk factors for exposure to Dengue are not easily identified and more research is needed. Assessing the awareness of WNV and its clinical importance showed that only 23% of participants had some knowledge of WNV, of which 76% knew that the infection was mosquito-borne and 47% recognized fever as a symptom. The identified lack of understanding and awareness was not surprising since WNV is not a visible disease in Mexico. Since WNV persists in an enzootic cycle in Niagara and the occurrence of future outbreaks is unpredictable, the agricultural workers remain at risk for transmission. Therefore it important they receive sufficient health education regarding WNV before leaving Mexico and during their stay in Canada. Conclusions. Human transmission of WNV could not be proven among the study participants even when due to their occupation they are at high risk for mosquito bites. The limitations of the study sample do not permit generalizable conclusions, however, the study findings are consistent with the absence of clinical cases in the Niagara Region, so it is likely that human transmission is indeed neglible or absent. As evidenced by our WNV serology results, PRNT must be utilized as a confirmatory test since false positivity occurs frequently. This is especially true when previous exposure to Dengue virus is likely.

Background. West Nile Virus (WNV), a mosquito-borne flavivirus, is one of an increasing number of infectious diseases that have been emerging or re-emerging in the last two decades. Since the arrival ofWNV to Canada to present date, the Niagara Region has only reported 30 clinical cases, a small number compared to the hundreds reported in other regions of similar conditions. Moreover, the last reported human case in Niagara was in 2006. As it has been demonstrated that the majority of WNV infections are asymptomatic, the question remains whether the lack of clinical cases in Niagara truly reflects the lack of transmission to humans or if infections are still occurring but are mostly asymptomatic. Objectives. The general objective of this study was to establish whether or not active WNV transmission could be detected in a human population residing in Niagara for the 2007 transmission season. To fullfil this objective, a cross-sectional seroprevalence study was designed to investigate for the presence of anti-WNV antibodies in a sample of Mexican migrant agricultural workers employed in farms registered with the Seasonal Agricultural Workers Program (SAWP). Due to the Mexican origin of the study participants, three specific research objectives were proposed: a) determine the seroprevalence ofanti-WNV antibodies as well as anti-Dengue virus antibodies (a closely related virus prevalent in Mexico and likely to confound WNV serology); b) analyze risk factors associated with WNV and Dengue virus seropositivity; and c) assess the awareness of study participants about WNV infection as well as their understanding of the mode of transmission and clinical importance of the infection. Methodology: After obtaining ethics clearance from Brock University, farms were visited and workers invited to participate. Due to time constraints, only a small number of farms were enrolled with a resulting convenience and non-randomized study sample. Workers' demographic and epidemiological data were collected using a standardized questionnaire and blood samples were drawn to determine serum anti-WNV and anti- Dengue antibodies with a commercial ELISA. All positive samples were sent to the National Microbiology Laboratory in Winnipeg, Manitoba for confirmation with the Plaque Reduction Neutralization Test (PRNT). Data was analyzed with Stata 10.0. Antibody determinations were reported as seroprevalence proportions for both WNV and Dengue. Logistic regression was used to analyze risk factors that may be associated with seropositivity and awareness was reported as a proportion of the number of individuals possessing awareness over the total number of participants. Results and Discussion. In total 92 participants working in 5 farms completed the study. Using the commercial ELISA, seropositivity was as follows: 2.2% for WNV IgM, 20.7% for WNV IgG, and 17.1 % for Dengue IgG. Possible cross-reactivity was demonstrated in 15/20 (75.0%) samples that were positive for both WNV IgG and Dengue IgG. Confirmatory testing with the PRNT demonstrated that none of the WNV ELISA positive samples had antibodies to WNV but 13 samples tested positive for anti-Dengue antibodies (14.1 % Dengue sereoprevalence). The findings showed that the ELISA performance was very poor for assessing anti-WNV antibodies in individuals previously exposed to Dengue virus. However, the ELISA had better sensitivity and specificity for assessing anti-Dengue antibodies. 111 .. - West Nile Virus in the Niagara Region Whereas statistical analysis could not be done for WNV seropositivity, as all samples were PRNT negative, logistic regression demonstrated several risk factors for Dengue exposure_ The first year coming to Canada appeared to be significantly associated with increased exposure to Dengue while lower socio-economic housing and the presence of a water basin in the yard in Mexico appeared to be significantly associated with a decreased exposure to Dengue_ These seemingly contradictory results illustrate that in mobile populations such as migrant workers, risk factors for exposure to Dengue are not easily identified and more research is needed. Assessing the awareness of WNV and its clinical importance showed that only 23% of participants had some knowledge of WNV, of which 76% knew that the infection was mosquito-borne and 47% recognized fever as a symptom. The identified lack of understanding and awareness was not surprising since WNV is not a visible disease in Mexico. Since WNV persists in an enzootic cycle in Niagara and the occurrence of future outbreaks is unpredictable, the agricultural workers remain at risk for transmission. Therefore it important they receive sufficient health education regarding WNV before leaving Mexico and during their stay in Canada. Conclusions. Human transmission of WNV could not be proven among the study participants even when due to their occupation they are at high risk for mosquito bites. The limitations of the study sample do not permit generalizable conclusions, however, the study findings are consistent with the absence of clinical cases in the Niagara Region, so it is likely that human transmission is indeed neglible or absent. As evidenced by our WNV serology results, PRNT must be utilized as a confirmatory test since false positivity occurs frequently. This is especially true when previous exposure to Dengue virus is likely.