WEST NILE VIRUS: 2004 Expected to Be Most Severe...

I S S U E R E P O R T

WEST NILE VIRUS:

2004 Expected to BeMost Severe Year Yet

TRUST FOR AMERICA’S HEALTH IS

A NON-PROFIT, NON-PARTISAN

ORGANIZATION DEDICATED TO

SAVING LIVES BY PROTECTING

T H E H E A L T H O F E V E R Y

COMMUNITY AND WORKING TO

MAKE DISEASE PREVENTION A

NATIONAL PRIORITY.

Source: Health Canada’s West Nile virusWeb site, Health Canada, http://www.west-nilevirus.gc.ca. © Her Majesty the Queenin Right of Canada, represented by theMinister of Health (2003).

JULY 2004

PREVENTING EPIDEMICS.PROTECTING PEOPLE.

The Centers for Disease Control andPrevention (CDC) predicts that the 2004West Nile season will be especially haz-ardous, with case counts expected to exceed2003’s total. Health officials also projectthat, for the first time, WNV will have a sig-nificant impact on the West Coast in 2004.The disease, which is spread to humans byinfected mosquitoes, has moved westward inthe U.S. with each successive season.

Early indications show that these projec-tions are on-target – this year’s first con-firmed human cases have mostly emerged inthe Plains states and far Western UnitedStates, in residents of Arizona, California,Nebraska, New Mexico, South Dakota, andWyoming, in addition to two cases inFlorida2 In California, WNV has been dis-covered in Imperial, Los Angeles, Orange,Riverside, San Bernardino, and Venturacounties as of June 24.3

Now that WNV has established a strongfoothold in the U.S., public health measuresshould reflect the changing nature of thedisease and its potential impacts.

WNV raises the following public healthconcerns:

� How to protect people most at-risk todevelop symptoms and complicationsfrom the virus, particularly those withcompromised immune systems, includ-ing: the elderly, cancer patients undergo-ing chemotherapy, and people with HIV.

� Additionally, though investigations arepreliminary at this time, there is con-cern that there may be a possible linkbetween WNV and birth defects. In2002, a pregnant woman contractedWest Nile virus and later gave birth to achild with several birth defects, whoalso tested positive for WNV.4

In five years since its first U.S. discovery in New York City in 1999, West

Nile virus (WNV) has become a permanent part of the U.S. health

landscape. The 2003 WNV season was the most severe ever. Nearly 10,000

people contracted the disease, which emerges each spring and peaks in the

summer and early fall. 2003 WNV activity was concentrated in the

Midwestern, Plains, and Rocky Mountain states, though human cases were

diagnosed in 45 states and the District of Columbia.1

2

In five short years, West Nile virus hasevolved from an isolated municipal eventinto a full-blown national epidemic. Theprojected West Coast emergence, combined

with the continued prevalence in the rest ofthe country, makes the 2004 season an espe-cially dangerous prospect.

� How to help communities evaluate thehealth risks or benefits of mosquito-reduc-tion strategies, including spraying of chem-icals that may raise other health concerns.

� How to diminish the hazard WNV posesto nationwide blood banks. In 2003, sixcases of WNV were attributed to blood-bank transmission, following 23 cases in2002.5 During the height of the 2003

WNV season, 2.5 million blood donationswere screened for WNV, leading to theremoval of over 800 infected donations.6

In this white paper, Trust for America’s Health(TFAH) will review the history and impact ofWest Nile virus, assess current control and pre-vention strategies, and offer recommenda-tions to improve our national readinessagainst WNV and other emerging diseases.

Tracing WNV’s Spread, 1999-2003

1999 2000 2001 2002 2003

West Nile Virus Human Case Count in U.S.,1999– 2003

0

2000

4000

6000

8000

10000

12000

HumanCase

Count

62 21 66

4156

9862

3

As the following images from CDC demonstrate, WNV has moved steadily westward witheach season.7

States and Counties Reporting WNVActivity, United States, 1999-2003*

Year # States # Counties Date Range

1999 4 28 9 Aug – 15 Nov2000 12** 145 6 Feb – 17 Nov2001 27** 359 8 Apr – 26 Dec2002 44** 2,531 3 Jan – 19 Dec2003 46** 2,289 1 Jan – 12 Dec

* Reported to ArboNET as of 1/20/2004** Plus D.C.

National Center for Infectious DiseasesWEST NILE VIRUS ACTIVITY

Cumulative results for 1999 calendar year

West Nile Virus Activity� Non-human WNV Activity� Human WNV Activity













“WEST NILE IS NOW WELL

ESTABLISHED IN AMERICA.

UNPREDICTABILITY IS THE

ONLY THING PREDICTABLE

ABOUT NEW INFECTIOUS

DISEASES. THE QUICK

EMERGENCE AND SPREAD

OF WEST NILE IS A

REMINDER THAT WE MUST

PROACTIVELY PLAN FOR

THE UNEXPECTED.”

– LOUIS W. SULLIVAN,

Former Secretary of the U.S.

Department of Health and

Human Services

4

West Nile virus (WNV), first identified in Uganda in 1937, infects

humans, birds, and horses. WNV is a type of virus that causes

encephalitis, or inflammation of the brain. The virus has been confirmed in

Africa, western Asia, the Middle East, the Mediterranean region of Europe and,

since 1999, the U.S.

CALIFORNIA’S VULNERABILITY

Beyond the previously noted westward migration of WNV, California is projected for a severe WestNile season in 2004 due to several factors: the state has a prevalence of agricultural areas with well-irrigated fields and a predominance of polluted urban waterways, both breeding grounds formultiple types of WNV-carrying mosquitoes. Additionally, California’s population density ensureshigh volume interactions with mosquitoes. In preparation for the onset of WNV, state health officials, working in concert with CDC, have been engaged in several preventative health measuresfocused on mosquito-population control and public education.8 However, a recent report by theRAND Corporation found California’s public health agencies are not uniformly prepared to respondto disease outbreaks and other important challenges – a dangerous development in a state certainto be impacted heavily by WNV.9

“We certainly have all the ingredients here in California for a major outbreak that involves two orthree different species of mosquitoes, where a lot of states may have just had to worry about one”10

–Dr. John Edman, Director of University of California Davis Center for Vectorborne Diseases

In people, most infections produce nosymptoms, or mild to moderate symptoms.An estimated 20 percent of people infectedwill develop West Nile fever. Symptoms mayinclude headache, fever, and body aches,often with skin rash and swollen lymphglands. More severe infections may bemarked by high fever, neck stiffness, muscleweakness, stupor, disorientation, convul-sions, paralysis, coma, and, rarely, death.The elderly, the very young, and individualswith weakened immune systems are mostlikely to develop West Nile fever.

WNV exists through a transmission cycleinvolving mosquitoes and birds. Mosquitoesbecome infected with the virus when theyfeed on infected birds, which carry the virusin their blood. Infected mosquitoes can

then transmit WNV to humans and animalsthrough biting. Testing for the virus inhumans involves collection of blood andcerebrospinal fluid to determine the pres-ence of antibodies to the virus. The incuba-tion period is generally five to 15 days fromthe time a mosquito carrying WNV infectsan individual.

There is no specific therapy for treatingWNV. In more severe cases, intensive sup-portive therapy may be necessary such ashospitalization, intravenous (IV) fluids, air-way management, respiratory support (ven-tilator), and prevention of secondary infec-tions (pneumonia). Currently, no vaccineto prevent WNV in humans is available,although clinical trials for such a vaccine areunderway. A vaccine for horses is available.

History of West Nile Virus

COLORADO’S WNV EPIDEMIC

In 2003, Colorado had more reported cases of WNV and related deaths from the virus than anyother state. Colorado reported 2,947 cases, compared to Nebraska’s 1,942, the state with thesecond highest number of cases. Sixty-one Colorado residents died after being infected. Over20 percent of Colorado’s cases developed into “neuroinvasive diseases,” serious illnesses thataffect the nervous system such as WN encephalitis and WN meningitis. These diseases causeinflammation in the brain (encephalitis) and of the membrane surrounding the brain and thespinal cord (meningitis), and can be fatal.

State budget cuts made the fight against WNV difficult in some parts of Colorado like LarimerCounty – one of the areas hardest hit by the virus. In 2002, the Larimer County Departmentof Health and Environment received $100,000 in federal public health preparedness money, butlost $700,000 due to state cuts. This budget reduction forced the county to reduce staff andcut a range of services. In the summer of 2003, this weakened agency faced a monumental chal-lenge: more than 500 county residents were infected with West Nile Virus. Lack of resourcesdelayed the county’s ability to fight back.12

5

In August 1999, wild birds, especially crows,began dying in significant numbers in NewYork. Several residents of New York Citycontracted encephalitis and, a month later,horses on Long Island were showing signsof illness.

Originally, a public health laboratory and theCDC identified the human cases as St. Louisencephalitis (SLE), the most common mos-quito-borne disease in the U.S. The deadbirds, rarely killed by SLE, were not believedconnected to the human cases. Dr. IanLipkin, currently at the Columbia University’sMailman School of Public Health, was thefirst scientist to publish a paper identifyingthe disease as West Nile virus.

Two weeks later, CDC changed its diagnosisto WNV. The two seemingly distinct animal

and human cases were indeed related.WNV is in the same family as SLE. The U.S.public health community was shocked at thediscovery of WNV, previously found only inAfrica, the Middle East, and Europe. Theoutbreak ended in the fall of 1999, but notbefore 62 people developed severeencephalitis, including 59 requiring hospi-talization, and seven who died.11

The lack of coordination between the ani-mal and public health communities resultedin a series of setbacks in identifying the truecause of the outbreak. This slowed the disease containment and public educationefforts in the important early stages whentime can mean the difference between con-taining an outbreak and the exponentialspreading of the illness.

Emergence of WNV

6

After the 1999 WNV outbreak, CDC createda West Nile Interagency Working Group,which facilitates information sharing andcoordination of activities among the rangeof agencies that have some connection todisease and wildlife control.

In 2000, CDC began publishing guidelinesfor surveillance, protection, and control of

WNV with input from a variety of scientistsand public health professionals, includingvirologists, epidemiologists, laboratory per-sonnel, wildlife biologists, and state andlocal health and agriculture officials. TheCDC also developed tests for use at state lab-oratories to diagnose WNV in humans, andprovided training on how to use them.

• INTERAGENCY COLLABORATION AND COOPERATION

• TRACKING AND SURVEILLANCE SYSTEMS

• LABORATORIES AND TESTING CAPACITIES

Interagency Collaboration and Cooperation

Public Health Responseto West Nile Virus

U.S. Department of Health andHuman Services (HHS)

• CDC is in charge of disease outbreakinvestigations, tracking, and diagnosisefforts, including management of theInteragency Working Group.

• CDC operates ArboNET, the electronicsurveillance system for tracking mosquito-borne infections.

• Food and Drug Administration (FDA)protects against the risk of contaminatingthe nation’s blood supply.

• National Institutes of Health (NIH)engages in research and testing of thevirus and develops related treatments.

U.S. Department of Agriculture

• Tracks WNV’s impact on U.S. livestockand poultry.

• Conducts research to develop methodsfor surveillance, monitoring, prevention,and control among animal populations.

U.S. Department of Commerce

• Conducts research on the impact of climatepatterns on mosquito populations and helpsdevelop plans for mosquito control.

U.S. Department of Defense

• Conducts research and testing initiatives toprepare and treat the military and public.

• Tests the impact on the Armed ServiceBlood Program.

Environmental Protection Agency

• Researches and tracks the impact of pesti-cides used in prevention efforts.

U.S. Department of the Interior

• Assists states with diagnosis of wildlifeinfections.

• Oversees control and prevention measures in National Park land.

State and local public health, agriculture,environmental protection, and wildlifeagencies also work to control WNV.

AGENCIES AND ORGANIZATIONS INVOLVED IN RESPONDINGTO WEST NILE VIRUS

7

West Nile tracking is performed throughCDC’s “ArboNET,” an electronic surveil-lance system that monitors WNV and othermosquito-borne illnesses. The tracking sys-tem facilitates information-sharing betweenCDC and numerous state and local publichealth agencies across the U.S.

Disease surveillance is a vital tool in helpingpublic health officials to understand how tocontrol and prevent disease. ArboNET allowsstates to track crows and other wildlife impact-ed by WNV, in addition to humans. Wildlifeprovide a key indicator for tracking thespread of the disease and demonstrating thecrucial and valuable need to connect humanand animal health efforts.

The isolated nature of ArboNET, however,means that key linkages to other disease pat-terns and contributing health, behavioral,and environmental factors, which are allinvaluable to effective disease prevention,are not being made. Currently, there is nota nationwide health tracking network thatcoordinates the monitoring of diseases andconnects them to possible related factors.This type of information would helpresearchers gain a better understandingabout which portions of the population aremost at-risk, and learn more about the caus-es and ways to control diseases.

Tracking and Surveillance Systems

RIFT VALLEY FEVER. THE NEXT WEST NILE?

Like West Nile virus, Rift Valley fever is a mosquito-borne disease native to Africa that is begin-ning to spread beyond the continent. Since 2000, cases of Rift Valley fever have been diagnosedin Yemen and Saudi Arabia, where approximately 100 persons died.13

The transmission cycle is similar to West Nile virus, through infected mosquitoes or throughcontact with infected animals (usually livestock). Past Rift Valley outbreaks in Africa have shownthat the disease can result in deadly hemorrhaging fevers and brain inflammations in a smallnumber of humans.14 Though death rates have varied widely in past human outbreaks, healthofficials worry that Rift Valley fever would have a significantly higher mortality rate than WestNile virus.15 The presence of American servicepersons in the Middle East, in addition to theincreasingly interconnected globe, makes common sense mosquito bite prevention against RiftValley a logical precaution.

“If we get Rift Valley fever in the United States, it would make West Nile look like a hiccup”

-Dr. Corrie Brown, Member of U.S. Secretary of Agriculture’s Advisory Committee for Animal andPoultry Diseases in Associated Press article.16

“WEST NILE VIRUS CAN BE

SEEN AS A HARBINGER OF

THINGS TO COME. IF WE

BETTER PREPARED OUR

PUBLIC HEALTH SYSTEM

WITH THE TRAINED

WORKFORCE, TECHNOLOGY,

AND CONTINGENCY

PLANNING AND FLEXIBILITY

IT NEEDS, WE WILL DO A

BETTER JOB OF PROTECTING

THE PUBLIC FROM THE

NEXT DEADLY DISEASE

WE ENCOUNTER.”

– ALLAN ROSENFIELD, MD,

Dean of the Mailman School

of Public Health at Columbia

University.

8

PUBLIC HEALTH LABORATORIES OVERVIEW

Public health laboratories consist of a loose network of federal, state and local laboratories thatwork in undefined collaboration with private clinical laboratories. They are responsible for arange of emergency response, disease surveillance, and specialized testing procedures.22

CDC rests atop the loose network of public health laboratories. CDC’s lab is the only civilianlaboratory in the country with comprehensive capacity to test for the presence of toxic chem-icals in the human body.23 Below the CDC, each of the 50 states (and the five territories) hasa state public health laboratory (SPHL).

State laboratories are not uniform in their capabilities, functions, or resources.24 Each state labwas created and operates independently under its state-defined charter and, consequently,varies widely from location to location. Many labs lack the capacity to continually monitor infec-tious agents or prepare for chemical or biological terrorism and face inadequate staffing andequipment concerns.25

Laboratory testing is needed before a casecan officially be classified as WNV. Lab testsmost often measure antibodies to WNV inthe blood of potential infected individuals.17

Most state labs are now self-sufficient in test-ing for WNV using the IgM antibody test. Inthe past, CDC tested every positive samplein its national labs for confirmation, butnow CDC acts in an advisory capacity and isprepared to offer testing and clinical assis-tance when called upon by laboratories.18

Re-testing of initial positives occurs whenthe patient may have been exposed to close-ly related viruses like SLE or to confirmresults from an insufficient sample size.19

Increasingly, state labs contract with privatelaboratories to handle the volume of testing,using procedures modeled after CDC test-ing protocols.20 The Association of PublicHealth Laboratories (APHL), state healthdepartments, FDA, and CDC monitor com-mercial testing procedures to ensure suit-able standards of accuracy.21

To prepare for the 2003 season, CDC’s FortCollins, CO manufacturing laboratory pro-

vided all states with testing solutions, specif-ically the reagents, to ensure cost-effective,high quality, and comparable results.However, the virus moved more rapidly andvirulently than anticipated, eventually over-whelming lab capacity and reagent supply.This failure to prepare for “surge capacity”violated the fundamental rule of planningfor worst-case contingencies when dealingwith new and emerging infectious diseases.

For 2004, CDC has contracted with FocusTechnologies, a Virginia-based firm, to pro-vide private-sector assistance in order toavoid the planning failures of the previousyear. However, the 2003 reagent shortageillustrates a larger problem: the continuedemphasis on reactive shortcuts instead of atrue investment in proactive solutions. Byinstitutionalizing flexibility, backup plans,and a wider-range of public-private partner-ships, CDC and the public health system ingeneral will be sure to avoid the persistentpitfalls of reactive planning, as illustrated bythe control and containment approach toWest Nile.

Laboratories and Testing Capacity

9

The long-term impact of mass mosquito spray-ing on the human population-at-large is stillrelatively unclear and needs much moreexamination. Additionally, the initial need formassive information gathering and researchcentered on the testing of infected birdspecies should be moderated in favor of pre-ventative education and control measures cen-tered on common sense and self-protection.Specifically, emphasis should be placed on:

� Education. Preventative measures,such as CDC’s ongoing “Fight theBite!” campaign are essential to effec-tive control of WNV. Awareness andeducation initiatives, such as eliminat-ing stagnant water around your homeand wearing insect repellent, are themost cost-effective and efficientmeans of controlling the impact ofWNV. (See sidebar for CDC IndividualRecommendations).

CDC has done an admirable job incommunicating common-sense pre-vention strategies through Web sites,multilingual public service announce-ments, and informational materialstargeted to public health profession-als, media representatives, and thegeneral public.

However, CDC and HHS could domore to educate the most vulnerablepopulations: very young children, theelderly, and people with weakenedimmune systems. CDC should workwith medical organizations such as theAmerican Academy of Pediatrics, the

American Medical Association, andthe American Nurses Association toencourage health professionals toalert vulnerable patients to the impor-tance of taking precautions againstWNV infection.

In addition, CDC should work withthe American College of Obstetriciansand Gynecologists and other healthcare practitioners to raise awarenessabout WNV among pregnant women.While the effect of WNV infectionsduring pregnancy is not fully under-stood, one case reported case in 2002suggests that intrauterine transmissionof WNV in certain instances mightaffect the newborn adversely.26 CDChas issued advice to pregnant womenwho live in areas with WNV-infectedmosquitoes (See box).

� Contingency Plans for IndividualBlood Donation Testing in Areas withHigh Rates of WNV Infection. In July2003, blood collection centers begantesting the blood supply for WNVusing a sophisticated method callednucleic acid technology (NAT). Thistesting method detects minuteamounts of the genetic material of thevirus in a person’s blood. After a per-son is infected with WNV, relativelyhigh levels of the virus remain in theirblood for an average of 6.5 days.27

During this timeframe, an individualwho donates blood could transmit theinfection to a recipient.

Trust for America’sHealth Recommendations

West Nile virus is now an unfortunate national reality. The focus of

public health efforts should be shifted in acknowledgement of the

disease’s permanence.

10

Currently, blood centers have tested“minipools” of blood, a batch of 6 to 16donations. If the test finds no viruspresent, then it is used. However, if theminipool tests positive, the blood ofeach individual donor in the pool isthen tested. Given that there are 2.5million blood donations a year, it is notfeasible to test all individual donorsdue to expense, and because therewould be too few trained laboratorypersonnel to conduct the tests.

However, all blood centers should havecontingency plans in place for conduct-ing individual donor testing using NAT.In cases of transfusion-associated trans-

mission of WNV in 2003, the two WNV-contaminated blood donations that ledto the transmission had screened nega-tive during initial minipool testing. Whenthe donations comprising the minipoolswere tested individually during a retro-spective examination, these two dona-tions contained very low levels of WNV.Blood Centers should have contingencyplans to test individual donations in areasthat might be experiencing a high num-ber of WNV infections. Individual dona-tion testing is being put into place atselected blood banks in Kansas,Nebraska, North Dakota, Oklahoma, andSouth Dakota for 2004.

WNV AND PREGNANCY 28

The potential health risks of West Nile transmission from mother to fetus during pregnancy isnot fully understood. While research is being conducted, officials recommend the followingpreventative options:

Common Sense Measures During Pregnancy: Pregnant women who live in areas withWNV-infected mosquitoes should apply insect repellent to skin and clothes when exposed tomosquitoes and wear clothing that will help protect against mosquito bites. In addition, when-ever possible, pregnant women should avoid being outdoors during peak mosquito-feedingtimes (i.e., usually dawn and dusk).

Evaluation of Infants Born to Mothers Infected with WNV During Pregnancy: When aninfant is born to a mother who was known or suspected to have WNV infection during preg-nancy, clinical evaluation is recommended. Infants should undergo a physical examination andevaluation for neurological damage or abnormalities.

Information From CDC “Fight the Bite!” Web site

Learn About Mosquito

Control

� Apply insect repellent � Be aware of peak

mosquito hours – duskto dawn

Mosquito-Proof Your Home

� Drain standing water� Install or repair screens

Help Your Community

� Report dead birds tolocal authorities

� Mosquito control pro-grams (Information line:1-800-858-7378)

HOW INDIVIDUALS CAN REDUCE THEIR RISK (According to the CDC)

11

The public health system’s response to WNVoffers insight into readiness to fight anyemerging infectious disease. As late as the2003 WNV season, public health officials andpolicymakers were reactive and shortsightedin control and command planning against thespread of WNV – elements that do not bodewell for the next emerging infectious disease.

In addition to these recommendations,combating West Nile virus, as well as otherhealth threats ranging from food-borne ill-ness to bioterrorism to chronic disease,requires a strong public health infrastruc-ture. The following recommendations aimto modernize public health by improvingdisease surveillance, laboratory capacity,and developing a more cohesive nationalsystem capable of responding to the myriadof 21st century health threats.

� Implementing a Coordinated DiseaseSurveillance System Must be aPriority. CDC launched the NationalElectronic Disease Surveillance System(NEDSS) in 2000 to integrate numer-ous surveillance and reporting systemsfor diseases such as hepatitis, vaccine-preventable illness, and tuberculosis inan effort to simplify disease reportingacross different jurisdictions and com-munications systems. Unfortunately,over 40 states and the District ofColumbia have yet to adopt a NEDSS-compatible system, largely due topiecemeal funding at the federal level.CDC appropriations for the systemtotaled $28 million in FY 2004, muchless than the $50 million public healthofficials have recommended.29

However, even with greater funding,NEDSS represents a stopgap solutionmasking a deeper problem. The lack ofa 21st century, integrated disease track-ing network hinders our ability to meet

pressing health threats ranging fromWNV to bioterrorism. The volume ofinformation gathered and cross-refer-enced across regional systems would bea cornerstone for rapid control andprevention strategies and timely andcoordinated responses.30 NEDSS is astep in the right direction, but notenough. A real investment to overhauland develop a nationwide health track-ing system is estimated at $275 million.

� Improved Laboratory Facilities: A 2003TFAH report concluded that our nation’slaboratories are unprepared to meettheir responsibilities as front-line defend-ers in our battles against the range ofhealth threats we face.31 A committedinvestment is needed to ensure that labo-ratories at the federal, state, and local lev-els are better prepared for their crucialdetection and response capabilities.Specifically, TFAH recommends:

� Federal and state public health labo-ratory capabilities need to be mod-ernized, including upgrading facili-ties and equipment and bolsteringthe workforce. This is essential ifpublic health laboratories are to havethe capability to respond to all healthhazards, including the ability to testfor antibodies as well as man madebiological agents, such as ricin orcyanide. The recommended invest-ment it will take to achieve this is$200 million in funding.

� CDC should retain and expand itsEmerging Infectious DiseaseCapacity Program to ensure thatstates have the ability to respond flex-ibly and rapidly to an outbreak andare able to develop contingencystrategic planning for emerging andspreading infectious diseases.

General Public Health System Improvements “WE NEED TO PLAN FOR THE

UNPREDICTABLE IN ORDER TO

MEET THE NUMEROUS POTENTIAL

CHALLENGES OF THE NEXT

DEADLY INFECTIOUS DISEASE –

WHICH IS SURE TO EMERGE

BEFORE WE ANTICIPATE.”

– KATHERINE KELLY,

President-Elect,

Association of Public

Health Laboratories

(APHL)

12

� Summit on Public Health Readiness:Whether responding to West Nile virus ora bioterrorism attack, the current effort toimprove the nation’s ability to respond tothe range of public health emergenciesfaces a significant organizational chal-lenge. Whatever the threat, the responseis largely dependent on the functioning ofa patchwork of state and local publichealth agencies, whose funding sources,bureaucratic structure, and responsibili-ties can vary significantly from state to

state and even county to county. It is clearthat the U.S. needs a more cohesive,national public health system. Towardsthat aim, the President, in consultationwith Congress and public health experts,should convene a White House summitthat will develop a concrete vision for thefuture of the American public health sys-tem and the resources needed to make ita reality. The summit would consider howthe country can best build a robust, inte-grated public health infrastructure.

AL(37)

MS(87)

AK

AZ(13)

AR(25)

CO(2947)

CT (17)

DE (17)

GA(50)

HI

ID(1)

IL(54)

IN(47)

IA(147)

KS (91)KY (14)

ME

MD (73)

MA (17)MI

(19)

MN(149)

MO(64)

MT(222)

NE(1942)

NV(2)

CA(3)

LA(123)

NH (3)

NJ (34)

NM(209)

NY(71)

NC (24)

ND(617)

OH(108)

OK(79)

OR

PA (237) RI (7)

SC (6)

FL (94)

SD(1039)

TN (26)

TX(717)

UT(1)

VT(3)

VA(26)

WA

DC (3)

WV(2)

WI(17)

WY(375)

WEST NILE VIRUS DISEASE 2003 HUMAN CASES, BY CLINICAL SYNDROME AS OF APRIL 14, 2004, 3AM MST*

These figures represent final numbers for 2003.**

Indicates human disease case(s) Avian, animal or mosquito infections#

*Currently, WNV maps are updated regularly to reflect surveillance reports released by stateand local health departments to the CDC Arbonet system for public distribution. Map showsthe distribution of avian, animal, or mosquito infection occurring during 2003 with numberof human cases if any, by state. If West Nile virus infection is reported to CDC Arbonet in anyarea of a state, that entire state is shaded accordingly.

Appendix:DATA FROM CDC’S ARBONET

13

ALMS

AK

AZ(6)

AR

CO

CT

DE

GA

HI

ID

IL IN

IA

KSKY

ME

MD

MAMI

MN

MO

MT

NE

NV

CA

LA

NH

NJ

NM(1)

NY

NC

ND

OH

OK

OR

PA RI

SC

FL

SD

TN

TX

UT

VT

VA

WA

DC

WV

WI

WY

2004 WEST NILE VIRUS ACTIVITY IN THE UNITED STATES(reported to CDC as of June 8, 2004*)

Indicates human disease case(s) Avian, animal or mosquito infections#

*Currently, WNV maps are updated regularly to reflect surveillance reports released by stateand local health departments to the CDC Arbonet system for public distribution. Map showsthe distribution of avian, animal, or mosquito infection occurring during 2004 with numberof human cases if any, by state. If West Nile virus infection is reported to CDC Arbonet in anyarea of a state, that entire state is shaded accordingly.

Data table:

Indicates avian or animal infection reported to CDC ArboNET for public distribution as ofJune 8, 2004 from the following states: Alabama, Arizona, Arkansas, California, Florida,Georgia, Illinois, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, New Jersey,New York, Ohio, Oklahoma, Pennsylvania and Texas.

Human cases have been reported in Arizona and New Mexico.

REPORT AUTHORS

Shelley A. Hearne, DrPH Executive Director Trust for America’s Health

Allan Rosenfield, MDDean, Mailman School of Public HealthColumbia University

Michael J. EarlsCommunications SpecialistTrust for America’s Health

Patti J. Unruh,Senior Communications AssociateTrust for America’s Health

Laura M. SegalDirector of CommunicationsTrust for America’s Health

PEER REVIEWER

Louis Sullivan, MDFormer Secretary, U.S. Department of Health and Human Services

Endnotes1 “2003 West Nile Virus Activity in the United

States,” Centers for Disease Control andPrevention. http://www.cdc.gov/ncidod/dvbid/westnile/surv&controlCaseCount03_detailed.htm 26 May 2004.

2 “2004 West Nile Virus Activity in the UnitedStates, Reported as of June 22, 2004,” Centersfor Disease Control and Prevention.http://www.cdc.gov/ncidod/dvbid/west-nile/surv&controlCaseCount04_detailed.htm.10 June 2004.

3 “California West Nile Surveillance InformationCenter,” California Department of HealthServices. http://www.westnile.ca.gov/ 8 June2004.

4 “CDC Seeks Data on Infants Born to Womenwith West Nile,” Center for Infectious Diseaseand Research Policy. CIDRAP News.http://www.cidrap.umn.edu/cidrapcon-tent/other/wnv/news/march0304wnv.html 3March 2004.

5 “Six West Nile cases in 2003 linked to donatedblood,” Center for Infectious Disease andResearch Policy. CIDRAP News.http://www.cidrap.umn.edu/cidrap/content/other/wnv/news/apr0804wnv.html 8 April 2004.

6 “Questions and Answers: Blood Transfusion,Organ Donation, and Blood DonationScreening Information,” Centers for DiseaseControl and Prevention. http://www.cdc.gov/ncidod/dvbid/ westnile/qa/transfusion.htm26 May 2004.

7 “Summary of West Nile Virus Activity, UnitedStates, 2003,” from “Fifth National Conferenceon West Nile Virus in the United States,”Centers for Disease Control and Prevention.http://www.cdc.gov/ncidod/dvbid/westnile/conf/ppt/ 10 June 2004.

8 “U.S. Poised for Epidemic West Nile Year,”CNN.com. http://www.cnn.com/2004/HEALTH/04/30/wnv.outlook 3 May, 2004.

9 RAND Report Raises Concerns About Parts ofCalifornia Public Health System, RANDCorporation. http://www.rand.org/news/press.04/06.02.html 2 June 2004.

10 “U.S. Poised for Epidemic West Nile Year,”CNN.com. http://www.cnn.com/2004/HEALTH/04/30/wnv.outlook 3 May 2004.

11 Ibid.12 “West Nile Battle Gets a Boost,” The

Coloradoan, 22 August 2003; “Worst is Over asState Tallies Up Outbreak’s Toll,” TheColoradoan,” 7 October 2003.

13 “CDC Watching Next for WorrisomeOutbreak,” Associated Press.http://www.phillyburbs.com/pb-dyn/news/94-05172004-301436.html 18 May 2004.

14 “Fact Sheet on Rift Valley Fever,” World HealthOrganization. http://www.who.int/mediacen-tre/factsheets/fs207/en/ 10 June, 2004

15 “CDC Watching Next for WorrisomeOutbreak,” Associated Press.http://www.phillyburbs.com/pb-dyn/news/94-05172004-301436.html 18 May, 2004.

16 Ibid.17 “West Nile Virus Q&A: Testing and Treating

West Nile Virus in Humans,” Centers forDisease Control and Prevention.http://www.cdc.gov/ncidod/dvbid/ west-nile/qa/testing_treating.htm 26 May 2004.

18 “Questions About Commercial Laboratories,”Centers for Disease Control and Prevention.http://www.cdc.gov/ncidod/dvbid/westnile/qa/testing_treating.htm#Commercial 10 June,2004.

19 Ibid

20 Ibid

21 Ibid22 Core Functions and Capabilities of State Public

Health Laboratories: A White Paper for Use inUnderstanding the Role and Value of PublicHealth Laboratories in Protecting our Nation’sHealth. Washington, DC: Association of PublicHealth Laboratories, 2000.

23 The CDC lab is exceeded in capabilities onlyby the U.S. Army Medical Research Instituteof Infectious Diseases (USAMRIID).USAMRIID is classified as a Level D labora-tory, the CDC is classified as Level C, andstate health laboratories are Level B andhospital and independent laboratories aredesignated as Level A laboratories.

24 Witt-Kushner, J., Astles, J., et al. “CoreFunctions and Capabilities of State PublicHealth Laboratories: A Report of theAssociation of Public Health Laboratories,”Morbidity and Mortality Weekly Report. 2002:37(51):S1.

25 Public Health Laboratories: Unprepared andOverwhelmed. Washington, D.C.: TrustforAmerica’s Health. June 2003.

26 “Interim Guidelines for the Evaluation ofInfants Born to Mothers Infected with WestNile Virus During Pregnancy,” Centers forDisease Control and Prevention. MMWR, 27February 2004 / 53(07): 154-157.

27 “Update: West Nile Virus Screening of BloodDonations and Transfusion-AssociatedTransmission — United States, 2003,” Centersfor Disease Control and Prevention. MMWR,9 April 9, 2004 / 53(13): 281-284.

14

15

28 “Interim Guidelines for the Evaluation ofInfants Born to Mothers Infected with WestNile Virus During Pregnancy,” Centers forDisease Control and Prevention. MMWR, 27February 2004 / 53(07): 154-157.

29 Quinlisk, Patricia MD, MPH, Medical Directorand State Epidemiologist for the IowaDepartment of Public Health. StatementBefore the Senate Subcommittee on Labor,Health and Human Services and EducationAppropriations. 3 October 2001; andGilchrist, Mary. Director, University HygienicLaboratory, University of Iowa and President,Association of Public Health Laboratories.Statement before the Senate SubcommitteeOn Labor, Health, Human Services,Education Appropriations. 3 October 2001.

30 Scutchfield, F. Douglas and Keck, C. William,Principles of Public Health Practice. Albany,New York. Delmar Publishers. 1997.

31 Public Health Laboratories: Unprepared andOverwhelmed. Washington, D.C.: TrustforAmerica’s Health. June 2003.

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