Department of Internal Medicine Division of Infectious Diseases
Dear Dr. Perkins, Infectious Disease physicians practicing in Dallas County and caring for patients with severe West Nile virus (WNV) disease met on August 3, 2012 at the Dallas County Health Department. We heard up-to-date information about the epidemiology of the WNV epidemic in Dallas County. This outbreak has rapidly evolved over the past weeks to be the largest WNV outbreak currently in the United States. With 123 cases of WNV and 6 deaths occurring in our County barely halfway through the season, this will likely become one of the largest urban WNV epidemics in the recorded history of the virus. The patients with severe WNV disease that we are currently caring for are very ill, and often in intensive care units. Even those who do not die from their illnesses will have a prolonged and difficult convalescence and rehabilitative course. Our deep concern for our patients and the high numbers of persons affected within a short few weeks prompt the writing of this letter. We applaud the activity of the Health Department staff in accumulating and analyzing the epidemiological data and want to cite particularly persons working in mosquito surveillance and control for their efforts and the challenging and sometimes dangerous work that they perform. The magnitude and extent of this outbreak, however, is of an unprecedented nature and represents a once in 50-year medical event. It rivals the 1966 Dallas St. Louis encephalitis epidemic, which resulted in 168 cases including 16 deaths. We want to stress the urgency with which our community needs to apply additional resources to controlling the mosquitoes which are responsible for spreading this outbreak. The CDC guidelines for such extreme outbreaks include control measures like aerial spraying to kill efficaciously adult mosquitoes carrying WNV.1 We commend the health department’s recent request to the State for more physical resources to augment conventional larviciding and ground-based adulticiding efforts. However, the severity of the current outbreak means that there are areas of intense WNV activity, which are not sufficiently responding to conventional ground-spraying and larvicidal control efforts. We strongly recommend requesting urgent State and Federal assistance to assess rapidly and implement enhanced additional mosquito control measures for this large-scale outbreak.2 At this time, as an alternative to widespread use of aerial spraying, we would advocate selective adaptation of aerial applications to specific areas with highest numbers of ongoing human cases despite usual ground-based control activities. Aerial spraying could be conducted of selected areas of the county that demonstrate the most intense viral activity in mosquitoes and humans. The data indicates that a greater concentration of cases is now occurring in parts of north Dallas County. Aerial spraying has been scientifically proven to be effective in reducing human illness from WNV. Historically, aerial spraying has been used effectively other outbreak circumstances in the US, including in Dallas in 1966 when such spraying successfully reduced mosquito infection rates for St. Louis encephalitis virus, from one in 150 mosquitoes being infected to less than one in 50,000 mosquitoes. We would also call attention to the Sacramento County California WNV epidemic in 2005 where aerial spraying effectively ended new human infections in areas which were sprayed, as compared to untreated areas.3 Aerial spraying was also used successfully in the urban New York City during their 1999 outbreak of WNV.
We think that the time to act is now and that delaying consideration of stronger aerial control measures will only lead to more tragic cases of severe illnesses. There have been over 40 new WNV infections per week reported in Dallas County residents over the past 2 weeks. The typical peak of illnesses in Dallas County occurs in August with a continuing number being reported for several more weeks. The public health risks from WNV this season clearly exceed the risks from exposure to mosquito insecticides.4 The economic cost of aerial spraying needs to be compared to the cost of the continued loss of lives, continued medical intensive care admissions, and the debilitating loss of function that the anticipated numbers of WNV victims encephalitis will suffer from this outbreak.5 Respectfully, Roger Bedimo, MD Associate Professor VA Christopher J. Bettacchi, MD North Texas Infectious Diseases Consultants Steven Gabe Davis, MD FACP Dallas ID Associates Edward L. Goodman, MD, FACP, FIDSA, FSHEA Texas Health Presbyterian Hospital of Dallas Jade Le, MD Assistant Professor, Infectious Diseases UTSW James Luby, MD Professor, Infectious Diseases UTSW Jane D. Siegel, MD Professor, Pediatrics UTSW Donald F. Storey, MD, FACP Dallas ID Associates Parisa Ann Suthun, MD Medical Clinic of North Texas Paul Southern, MD Professor, Pathology UTSW William Sutker, MD North Texas Infectious Diseases Consultants Mark Swancutt, MD Interim Chief, Infectious Diseases UTSW Marc A. Tribble, MD Baylor University Medical Center Gene Voskuhl, MD AIDS Arms
1. Centers for Disease Control and Prevention. Epidemic/Epizootic West Nile Virus in the United States: Guidelines for Surveillance, Prevention, and Control, 2003. http://www.cdc.gov/ncidod/dvbid/westnile/resources/wnvguidelines2003.pdf
2. Texas Department of State Health Services. Response Operating Guidelines: Vector Control 2012. (www.dshs.state.tx.us/commprep/response/ROG.aspx)
3. Carney RM, Husted S, Jean C, Glaser C, Kramer V. Efficacy of Aerial Spraying of Mosquito Adulticide in Reducing Incidence of West Nile Virus, California, 2005. Emerging Infectious Diseases. 2008, 14:747-54. 4. Peterson RK, Macedo P, and Davis RS. A Human-Health Risk Assessment for West Nile Virus and Insecticides Used in Mosquito Management. Environmental Health Perspectives. 2006, 114(3):366-372. 5. Schwab, P. Economic Cost of St. Louis Encephalitis Epidemic in Dallas, Texas, 1966. Public Health Reports. 1968, 83(1)):860-866.