ARBOVIRUS

Dr. Priyo Budi Purwono, M.Si.

Departemen Mikrobiologi Klinik
Fakultas Kedokteran Universitas Airlangga
Surabaya, April 2014
 TODAY’S TOPICS
1. Introduction of ARBOVIRUS
2. Dengue virus
3. Cikungunya virus
4. Yellow Fever virus
5. Ebola virus *
 ARBOVIRUS (Introduction)
• =Arthropod borne virus  Exotic viruses
• Transmitted by bloodsucking arthropod from one
vertebrate host to another
• Mosquito, tick, phlebotomus
• Multiply in tissue of arthropod
• Trans-ovarian transmission in arthropod
• Geographical distribution pattern
• Related to season and environment
• Main clinical syndrome : Fever, Encephalitis,
Hemorraghic, (poliarthritis)
Classification Viruses Common Diseases Region
Flavivirudae Dengue vi * Haemoragic, Shock America, Asia, Africa
(Flavivirus) Yellow Fever vi * Joundice,hemoragic,RF South America, Africa
West Nile vi Meningoencephalitis Africa, Amrc, Europe, ME
Jap B Encephalitis vi Encephalitis China, Japan, Korea, Asia

Togaviridae Cikungunya vi * Joint pain Asia

O’Nyong-nyong vi
Filovorodae Ebola vi * (non Hemorrhagic Africa, America
arbo)
Bunyaviriudae Rift Valley fever vi Encephalitis
Reoviridae Colorado tick fever vi Joint pain America (tick)
 Dengue virus
• Dengue : Breakbone fever
• Mild  moderate  severe
• Mild : fever (DF), headache, muscle and joint
pain
• Moderate : nausea, vomiting
• Severe : Haemorrhagic sign (rash, bleeding) 
DHF, Shock (Dengue Shock Syndrome/DSS)
• Endemic more than 100 countries
• Vector transmission : mosquitos
 Dengue virus profile
• Genus : Flavivirus, Family : Flaviviridae
• spherical, diameter 50 nm
• Three structural proteins (C, prM, E) and seven non structural proteins
• single stranded RNA virus, positive senses
• four serotypes (DEN 1 to 4)

• Asian genotype DEN 2, DEN 3  severe cases

• Viral protein, RNA syntesis : cytoplasma host cell
• replication : 15 h after inf
• Viremia : plasma, platelet, lymphocyte, monocyte
 Epidemiology of Dengue
• Aedes aegyptii : primary vector (female)
 8-14d become infective in range 1-3 m
• Tropical and subtropical region
• 50 million cases/yr and 400,000 cases of DHF
• Leading cause of childhood death in Asian
• DHF Case Fatality Rate : 15 %
• Primer inf  Asymptomatic vs symp 15 : 1
• Secondary inf  more severe
• First epidemi : Manila, 1953
• Indonesia : Jakarta & Surabaya, 1968
Geographical Distribution of Dengue Infection cases (Simmons, 2012)

• South East Asia : 75 % cases

• India, Bangladesh, Polinesia
• South America
• Eastern and Western Africa
• Mediterania
• 35 N – 35 S
• low land (<1000 meters) 
climate change
 Clinical Manifestation
• Onset : 4-7d after infective mosquito bite
• Symptom : sudden fever (saddleback pattern),
prodromal symptom (malaise, chill, headache)
• Pain : back, joint, muscles, eyeball, deepbone
• Others : Rash, lymphnode enlarge
• Viremia : onset to 3-5 days

Three phases :
1.Febrile phase : high fever, dehidration, neurological disturbance, seizure
2.Critical phase : hemorrhagic, plasma leakage, shock, organ impairment
3. Recovery phase : hipervolemia
 DENGUE INFECTION TIMELINE :
SEVERE SYNDROME :

1. Dengue Hemorrhagic Fev

- bleeding sign
(rash/ptechiae, epistaxis,
haematemesis, melena)
- passively acquired antibody
- preexist heterologous
antibody
2. Dengue Shock Syndrome
- plasma leakage, shock and
haemoconcentration
- type 2 following type 1
virus infection
- Non neutralizing antibodies
Ptechial rash in infant Minor bleeding on injection site

Hematome on skin Makular rash in recovery state

Dengue Classification (WHO, 1997)
• Dengue Fever
• Dengue Hemorrhagic Fever (DHF)
DHF grade 1 : DF with Torniquet test positive
DHF grade 2 : + spontaneus bleeding
DHF grade 3 : + decrease blood pressure
DHF grade 4 : + shock (Dengue Shock
Synd/DSS)
 Dengue Classification (WHO, 2009)

Severe plasma leakage :

Probable Dengue Fever : Warning sign Dengue Fever : -Shock
• Live or travel to • Abdominal pain - Respiratory distress
endemic area • Persistent vomiting
• Fever and 2 following : • Fluid accumulation -Severe bleeding :
- nausea, vomiting • Mucosal bleed hematemesis, melena
- rash • Lethargy
- aches, pain • Liver enlargement -Severe organ impairment :
- torniquet test positive • increase HCT Liver : AST or ALT >1000
- leukopenia • rapid decrease platelet Impaired consciusness
Heart and other organ
 Related Hypothesis in severity
of dengue infection
1. Antibody Dependent Enhancement
- most common hypotesis in Dengue
- secondary infection by heterolog serotype
2. Molecular characteristic (virus type)
- DEN II strain Asian  suggested virulent
3. Molecular mimicri
- Similarity virus antigen with host protein
4. Host factor
- polimorphisme, host imunnity
Antibody Dependent Enhancement
 Differential Diagnosis
• Viral infection :
Yellow fever vi, Japanese B encephalitis vi, Ebola vi, Mamburg
vi, Cikungunya vi, West Nile vi, Measless vi, enterovirus,
influenza like illness, etc

• Bacterial infection :
Leptospirosis, thypoid fever, ricketsial infection

• Parasite infection : malaria

Subjective parameters : Objective parameters :

Anamnesis : - Physical examination
Type of fever, illness history, bleeding history, - Routine blood lab exam
Previous illness, Environment, Family History, - Suggestive tes
Traveling history, Occupation, ect - Confirmed tes
 Diagnosis
• Klinis :
- Fever, Hemorrhagic, Shock
- Vital sign, Physical examination
- Torniquet test

• Laboratory diagnosis
- Routine test : Leukopenia, Platelets, Hemoconcentration
- Serologis : NS1 antigen, IgM-IgG anti dengue (paired*)
- Polimerase Chain Reaction *  serotype
- Virus culture/cell line *
: C6/36, AP61 (mosquito cell);
: Vero cell, LLMK2, BHK21 (mamalian cell)
 Treatment and Prevention
• Grup A : DF without WS : Home care
• Grup B : DF with WS : Hospital care
• Grup C : Severe DF : Intensive care
• Fluid therapy
• Symtomatic : Antipiretic, Antimimetic, Vitamin

PREVENTION
• Enviromental control
• Vectrol control : Larvacide, Adultcide
• Individual and house protection
• Surveillance
• Vaccine ???
 Yellow Fever virus

• Flavivirus
• Africa, south america
• Vector : Aedes aegypti
• Liver-renal dysfunction, Hemorrhage mortality
• Seven genotype (5 africa, 2 south america)
• Mosquito  skin  spread to local lymph nodes,
liver, spleen, kidney, bonemarrow, myocardium 
necrotic lesions in liver and kidney (jaundice, renal
failure); spleen, lymphnode, heart; myocardium
(shock)
 YFV infection (sign and symptom)
• Incubation period : 3-6 days
• Fever, chills, headache, dizziness, myalgia,
backache
• Nausea, vomiting, bradycardia
• Viremia : several days  period of infection
• 15% : severe case  hepato-renal failure: fever,
jaundice, renal failure, hemorrhagic-hematemesis
• Neutralizing antibody : develop a week  life
• Die or recover completely
• Mortality : 7-10 days illness
 Diagnosis of YF
• Anamnesis : type of fever, travel history
• Physical examination
LABORATORY EXAMINATION
• Virus detection :
- first 4 days after onset (from blood)
- virus antigen detection : ELISA, IHC
- nucleic acid : PCR
• Serology test :
- IgM : during first week (ELISA)
- fourfold or greater titer  confirmation
 Treatment and Prevention

• No antiviral therapy
• Supportive treatment : symptoms

PREVENTION
• Environment
• Vector control
• Individual and house
• Surveillance
• Vaccine : 17D strain (attenuated live vaccine)
CHIKUNGUNYA VIRUS
• Arbovirus
• Fever and polyatralgia
• Occurs as large outbreak
• Africa, Asia, Europe, Indian and Pasific Ocean
• Genome : SS RNA
• Genus Alphavirus
• Family Togaviridae
• Mosquito : Aedes aegypti and Aedes albopictus
(aggressive at daytime)
• Human as primary host
EPIDEMIOLOGY OF CHIKUNGUNYA
 Chikungunya cases : South East Asia, South
Asia, Polinesia, Africa, Europe (France,
Germany, Italy)
SIGN AND SYMPTOM
• Majority infected become symptomatic
• Incubation period 3-7 days
• Onset : fever and polyathralgia
• Joint : hands and feet  can be severe
• Others : headache, myalgia, nausea, vomiting,
conjunctivitis, or macopapular rash
• Resolve within 7-10 days
• Rare complication : uveitis, retinitis, myocarditis,
hepatitis, nefritis, meningoencephalitis, hemorrhage,
GBS, cranial nerve palsy
• Severe risk grup : neonates, older, hypertension, DM,
cardiovascular disease
LABORATORY DIAGNOSIS

 Routine test : Lymphopenia, trombocytopenia,

eleveted creatinin, hepatic transaminase
 Further test :

- Viral culture : first 3 days

- RT PCR : first 8 days
- Serology : IgM, IgG (end of first week)
TREATMENT AND PREVENTION
• No antiviral therapy
• Supportive treatment :
- rest, fluid
- Antipiretic, NSAIDs

PREVENTION
- House : air conditioning/window screen
- Mosquito rappellent
- Wear long shirt and long pants
- Environment and vector control
- No vaccine
 Ebola Virus (EBOV)
• Ebola Haemoragic Fever (EHF) : 1976 first recognized
• Ebola virus  ebola river (RD Congo, Africa)
• Filoviridae : genome ss RNA (Zoonotic Inf)
• Pleomorphic, filamentous (D: 80nm, length: 805nm)
• 5 subtype of Ebola Virus (EBOV)
- ZEBOV (Zaire EBOV)
- SEBOV (Sudan EBOV) Human disease

- BEBOV (Bundibugyo EBOV)

- ICEBOV (Ivory Coast EBOV)
Primates/non human
- REBOV (Reston EBOV) disease
 EBOV pathogenecity
• Ebola HF : Frequent cases in Africa
countries
• Mortality rate : ZEBOV is the highest
pathogenic agent
• Reservoir :
- fruit bats
- orangutan ?
- pig ?
• Susceptible host :
- monkeys (Macaca)
- apes (gorilla, chimpanzee)
- human
• Transmission :
- direct contact (blood, body fluid)
- animal to human ?
 Clinical Disease (EHF)
RT PCR (-1/?)
Diagnostic Testing

Antigen (3/16)
/
Ig M antibody (2/168)

IgG antibody (6/749)

-5 0 5 10 15 20 25 30 35….// days after onset

Prodrome : fever, chill, myalgia, sore
0 to 11 throat, cough, skin rash
Manifestation
Clinical

7 to 16 Fatal cases : haemoragic, anuria,

tachypnea, shock

6 to ….. Survivor : myalgia,

athralgia, hepatitis, hearing
loss, ocular disease
 African
EBOV Subtype :
ZEBOV
SEBOV
BEBOV
ICEBOV
REBOV

ZEBOV
SEBOV
ICEBOV
BEBOV
 Natural Reservoir ?
Fruit bats (pteropodidae)
Others ?

•Reservoir species is expected to be largely asymptomatically

or persistently infected
Whatever reservoir
Known mechanism – outbreaks are sporadic
•Reservoir species that infrequently contact with human,
AMPLIFYING
Suspected
great apesmechanism
and occasionally otherHOST
mammals
?
•Reservoir species with viral “dormancy” that will be
Hipothetical mechanism
activated under specific circumstance
• No antiviral therapy
 Treatment and Prevention
• No spesific antiviral
• Isolation facilities in hospital
• Strict barrier nursing technique
• Take care of infected blood, secretion, tissues,
wastes
• Transportation and care of nonhuman
primates  especially from endemic country
• No vaccine  under developement