LIFE CONOPS: Development & demonstration of management plans against -the climate change enhanced- invasive mosquitoes

in S. Europe

The national plan in Italy for the preventionof vector born diseases

Raffaella Angelini

Public Health Department – AUSL Romagna

Chikungunya in Emilia-Romagna 2007

G. Rezza et al., Lancet 2007, 370 1840-46

Index case lab confirmed: 1Lab confirmed: 217 Probable, drawing denied: 30Lab negative: 89

A total of 247 probable/confirmed cases, from four provinces (Ravenna, Forlì-Cesena, Rimini, Bologna)

Number of cases by lab results(July 4th, 2007 – September 28th, 2007)

Human national mandatory surveillance system - Italy (D.M. 15-12-1990): imported and authoctonous VBD

• “Classe I”: yellow fever, viral hemorrhagic fever, plague, esanthematic typhus Notification within 12 hours

• “Classe II”: rickettsial infections ≠ from esanthematic typhus, tularemia, cutaneous & visceral leishmaniasis Notification within 48 hours

• “Classe IV”: outbreaks (aggregated data) Notification within 24 hours

• “Classe V”: other infectious diseases, including vector borne diseases not included in previous classes No prescribed term

Special surveillance of WNND, Dengueand Chikungunya

• The increasing number of confirmed human cases from 2008 to 2009 and the occurrence of the WNV in a larger geographical area in 2009 prompted the Ministry of Health to publish, in spring 2010, a national program for WNND human surveillance, integrating information from veterinary and vector surveillances.

• Subsequently, in 2011, a new national plan on integrated human surveillance of imported and autochthonous vector-borne diseases (Chikungunya, Dengue and West Nile disease) was issued, with annual update in 2012.

Italian MoH directive: Surveillance of WNV

disease in Italy, 2010

• Between June 15 and November 15.

• Integrated human and veterinary surveillance.

• Defining the risk:

− “affected area”: province areas (secondary administrative unit) with positivity in the veterinary surveillance or autochthonous lab. confimed animal/human cases.

− “surveillance area”: regions (surrounding an affected area) with vector presence and with autochthonous animal/human cases within its Provinces.

Italian MoH directive: Surveillance of WNV

disease in Italy, 2011

• It includes surveillance of Chikungunya e Dengue

• Defining the risk:

− “affected area”: area (Provinces) with positivity in the veterinary and enthomological surveillances or autochthonous animal cases or lab. confimed human cases.

− “surveillance area”: subnational area (Regions) with vector presence and with autochthonous lab. confirmed animal/human cases within its Provinces.

• Between June 15 and November 15 for autochthonous cases and permanent for imported ones.

Italian MoH directives: adjustmentfrom 2012 to date

• 2014: Zika virus was included

• 2016: Split in two national preparedness Plans

− One for West Nile virus integrated with the veterinary and entomological surveillance for rapid risk assessment

− One for Arbovirosis transmitted through invasive mosquitoes, with particular focus on Chik, Den and Zika virus infections

• 2017: A National plan for TBE surveillance was published

How the system works

Public Health Response

Entomologicalinvestigations

Epidemiological investigations

Early detection of human cases

Vector control

Scientific Committee

Regional group + Municipalitiesto fight mosquitoes

Early detection of human cases

• Surveillance of imported cases throughout the year

• Strict cooperation of Local and regional Health Authorities with MoH and ISS

• Specific training of health professionals on early diagnosis and treatment

• During the vector activity period (June – October):

− Strengthened surveillance based on active case research

− Strengthened contacts with family doctors

Chikungunya case definition

• Probable case: a patient meeting the clinical and epidemiological criteria (staying in a Country endemic for the disease during the 15 days period before the disease onset) and IgM anti-Chik positive in serum.

• Confirmed case: a probable case and at least one of the following laboratory criteria:

− PCR - test positive in a clinical sample

− Viral isolation in a clinical sample

− Antigen identification in a clinical sample

− IgM positive confirmed by neutralization test

− Seroconversion or 4 fold increase in antibodies

Dengue case definition

• Probable case: a patient meeting the clinical and epidemiological criteria (staying in a Country endemic for the disease during the 15 days period before the disease onset) and IgM anti-Dengue positive in serum.

• Confirmed case: a probable case and at least one of the following laboratory criteria:

− PCR - test positive in a clinical sample

− Viral isolation in a clinical sample

− Antigen identification in a clinical sample

− IgM positive confirmed by neutralization test

− Seroconversion or 4 fold increase in antibodies

Zika case definition

• Probable case: a patient meeting the clinical, epidemiological criteria (staying in a Country endemic for the disease during the 15 days period before the disease onset, or sexual contacts with a confirmed or suspected cases) and IgM anti-Zika positive in serum.

• Confirmed case: a probable case and at least one of the following laboratory criteria:

− PCR - test positive in a clinical sample

− Viral isolation in a clinical sample

− Antigen identification in a clinical sample

− IgM positive confirmed by neutralization test

− Seroconversion or 4 fold increase in antibodies

Human surveillance data transmissionSurveillance period June 1st - October 31st

Clinician/Practitioner

detecting a possible / probable case

Ausl

Public Health Department

Regional Authority

Ministry of Health

ISS

Regional Reference Laboratory

National Arbovirosis Reference Laboratory

Dip. MIPI – ISS

ALERTBIOLOGICAL

SAMPLES

within 24 H

REPORTING

within 12 H

Municipalities

for mosquitoes disinfestation

Laboratory capacity

Network of Regional

ReferenceLaboratories

Vector control

• Municipalities strengthened vector control both on larvae + adults (in case of imported cases and/or autochthonous outbreak)

• Regional group preparation of administrative acts, guidelines collaboration with entomologists

Vector control: routine measures

• Larvicide distribution in manholes on public roads

• Use of adulticides in sensitive sites hearing Local Health Unit

• Information and involvement of citizens on the management of their own gardens

Control measures: confirmed or suspected cases

• WHERE: Mosquitoes control activity are to be carried out − in a radius of 100 m around every single suspected case− in a radius of 300 m around a cluster of cases

• HOW: the protocol− Use of larvicide (Insect growth regulators or Bacillus

thuringiensis) in every manholes− Door-to door interventions for elimination of breeding sites− For 3 nights in succession use of fast acting insecticides

applied by truck mounted atomizer or backpack mist blower

Public Health Measures on blood, organand cells transplantation

Precautionary measures:

• Stop of blood donations from residents in affected areas

• Stop for 21 days from people staying in affected areas even for a very short time

• Coordination with Donors Associations to maintain blood supply

• Stop of organ and cells donation in affected areas

Disinsection

• All aircrafts landing at Italian

airports, regardless of their

origin, must present a residual

disinsection certification in

accordance with Annex 9 of the

Convention of the ICAO.

Communicationand information

Italy: autochthonous

cases of Chikungunya virus(updated 10 November 2017)

A focus on Emilia-Romagna

Chik/Dengue/Zika cases in Emilia-Romagna; 2008-2017

* Update 6/11/2017

In 2017 detected 4 cases of Chikungunya related to travel in Calabria e Lazio

Entomological surveillance

• Ovitraps located in the 10 largest Municipalities• Sampling every 14 days• Samples read in the lab of ARPAE (Environmental Agency)• Data published on website www.zanzaratigreonline.it• Maps to individuate area with higher infestation

Comune

N.

ovitrappole

2017

N.

substrati

10 turni

Parma 60 600

Piacenza 60 600

Reggio Emilia 60 600

Modena 60 600

Bologna 110 1100

Ferrara 90 900

Ravenna 100 1000

Cesena 75 750

Forlì 60 600

Rimini 80 800

Totale 755 7.550

Entomological surveillance 2017

Discussion

• Crucial for the system that the reference Lab maintains an high

standard in the timing of testing to allow a quickly

disinfestation.

• In recent years Municipalities have reduced the budget for

vector control due to economic crisis but also because the issue

of Vector borne disease is considered no more a real health risk

(too time passed from 2007 outbreak experience).

• It is important to gain more engagement of people in the

management of their gardens and backyards (in our towns

more than 60% of manholes is in private properties).

Conclusions

• The regional plan is effective: every year we face a number of

imported cases but we have never experienced autochthonous

transmission after the outbreak of 2007.

• In 2017 the system has proved its sensibility promptly detecting

suspected cases in citizens who had not traveled abroad but

coming from the Italian regions where chikungunya outbreak

was ongoing.

• It is crucial to maintain an high sensibility in clinicians and

General practitioners with continuous training and updating on

epidemic data and on the geographical areas where viral

circulation is ongoing.

Thank you for your attention and

thanks to all the Emilia-Romagna

working group.

• raffaella.angelini@auslromagna.it