WNV Surveillance Detects Jamestown Canyon Virus (3)

The following comment on the cost/benefits of viral surveillance and
diagnostics, from several perspectives. All are forwarded from
ProMED-mail <http://www.promedmail.org> in response to postings last
week re: detection of Jamestown Canyon virus in Upstate New York, in
the course of current surveillance for WNV.

[1] Institutional Memory, Funding, Diagnosis & Treatment. Calisher and
Grimstad
[2] Suffolk County, New York, Surveillance Detects Flanders Virus.
Ninivaggi
[3] Viral Diagnostics, Cost-Benefit Considerations. Peters

-------------------------------

[1]
Date: 6 Aug 2004
From: Charles H. Calisher <calisher@cybercell.net> and Paul R. Grimstad
<grimstad.1@nd.edu>
Source: ProMED-mail ID 20040807.2171 [edited by ProMED]

INSTITUTIONAL MEMORY, FUNDING, DIAGNOSIS & TREATMENT

The recent report on ProMED (ID 20040805.2137 ) of the discovery of
Jamestown Canyon virus (family _Bunyaviridae_, genus Orthobunyavirus)
in Clinton County, NY should serve as a reminder to us all that the
wheel is being reinvented every day. The occurrence of this virus in
NYS is well-known, and this virus has been shown to infect large
numbers of people throughout the eastern U.S. (1-4).

Not only is institutional memory being lost as funding for laboratories
fluctuates, depending on politics and need, but it appears that fewer
people read the literature these days, depending entirely on hearsay or
what they can find on PubMed.

In recent years, in response to "managed care" and "cost savings",
suspected bacterial and viral infections often are treated empirically,
without cultures or further laboratory investigations. The patient is
given whatever antibiotic is all the rage and told to return if
symptoms persist. After greater than 50 years of academic advancements,
this paradigm should be considered [lower] quality [where more
sophisticated resources are available]. It might be eye-opening were
hospitals to perform cost-benefit studies on the benefit to the patient
of treating without lab results.

As more and more infections are being "discovered" and considered
"emerging" or "reemerging", it would do the discoverers well to
determine whether all s/he knows is all there is to know. Worse,
targeted surveillance, e.g., for West Nile virus alone, or for
whatever the disease du jour may be, allows the less glamorous, less
prevalent agents to slip through the cracks. Worse, there may be
agents of disease, such as Jamestown Canyon virus and Cache Valley
virus (5), which are not looked for and therefore are not found as
etiologic agents. If we do not knock, the door will not be opened.

1. Grimstad, P.R., C.L. Shabino, C.H. Calisher, and R.J. Waldman. A
case of encephalitis in a human associated with a serologic rise to
Jamestown Canyon Virus. Am. J. Trop. Med. Hyg. 31:1238-1244, 1982.

2. Grimstad, P.R., R.N. Haroff, B.B. Wentworth, and C.H. Calisher.
Jamestown Canyon (California serogroup) is the etiologic agent
of widespread infection in Michigan humans. Am. J. Trop. Med. Hyg.
35:376-386, 1986.

3. Deibel, R., S. Srihongse, M.A. Grayson, P.R. Grimstad, M.S. Mahdy,
H. Artsob, and C.H. Calisher. Jamestown Canyon virus: the etiologic
agent of an emerging human disease? in: Proc. Int'l. Symp. Calif.
Serogr. Viruses. C.H. Calisher and W.H. Thompson (eds.). Alan R.
Liss, Inc., New York, pp: 313-325, 1983.

4. Grayson, M.A., S. Srihongse, R. Deibel, and C.H. Calisher.
California serogroup viruses in New York state: a retrospective
analysis of subtype distribution patterns and their epidemiologic
significance, 1965-1981. in: Proc. Int'l. Symp. Calif. Serogr.
Viruses. C.H. Calisher and W.H. Thompson (eds.) Alan R. Liss, Inc.,
New York, pp: 257-267, 1983.

5. Calisher, C.H. and J.L. Sever. Are North American Bunyamwera
serogroup viruses etiologic agents of human congenital defects of the
central nervous system? Emerg. Infect. Dis. 1:147-151, 1995.
<http://www.cdc.gov/ncidod/eid/vol1no4/calishr3.htm#top>

--
Charles H. Calisher, Ph.D.  <calisher@ cybercell.net>
Professor, Arthropod-borne and Infectious Diseases Laboratory
Department of Microbiology, Immunology and Pathology
College of Veterinary Medicine and Biomedical Sciences
Colorado State University, Ft. Collins, CO 80523
Paul R. Grimstad, Ph.D.   <grimstad.1@nd.edu>
Director, Undergraduate Studies
Department of Biological Sciences
Center for Tropical Disease Research and Training
University of Notre Dame, Notre Dame, IN  46556-0369
[ProMED Moderator MPP Comments: Drs. Calisher and Grimstad are raising
some very valid points above.  A key issue here seems to be "seek and
ye shall find".  In ref. 2 cited above, the authors sought and found:
among 780 Michigan residents tested for neutralizing antibodies to
California serogroup viruses, 216 (27.7 percent) were found to have
specific neutralizing antibody to Jamestown Canyon virus.
It does appear as though the increased surveillance in response to WNV
activity in the USA is having the beneficial outcome of further
identifying other viral agents in our environment that have been absent
from the collective radar scope outside of academic-oriented
institutions.  In the clinical arena, the diagnosis of "viral syndrome"
is one of the most common for self-limited febrile illnesses, which are
rarely
studied further as to etiology, unless it is an unusual presentation or
more severe illness.  But even then -- as is suggested above -- there
are
more severe illnesses that still go undiagnosed in terms of etiologic
agent.
The bean counters would argue the cost-benefit ratio is against
diagnostic testing in the absence of agent-specific treatment
modalities. Methinks there's a mid-point that has yet to be reached in
this debate -- the current "all or nothing" choices seem less than
adequate.]
--------------
[2]
Date: Fri 6 Aug 2004
From: Dominick Ninivaggi <Dominick.Ninivaggi@co.suffolk.ny.us>
Source: ProMED-mail  ID 20040808.2187
SUFFOLK CO, NEW YORK SURVEILLANCE DETECTS FLANDERS VIRUS
Suffolk County, Long Island, New York has picked up some 20 isolations
of Flanders virus in _Culex_ spp., in 2004, during the course of its
arbovirus surveillance. This virus is non-pathogenic to humans and is
named after a community in Suffolk County. I agree with the assessment
that part of the reason that we are seeing more of this virus is
improved surveillance, including more use of Vero cells in the State
lab to screen for all arboviruses. The finding of live Flanders virus
in our samples gives additional assurance that our Arthropod Borne
Disease Lab is handling the mosquitoes correctly.
[ProMED Moderator MPP Comments: Dr. Ninivaggi's remarks reinforce the
view that increased surveillance for WNV is resulting in detection of
several pathogenic, and nonpathogenic, viruses, which, previously,
would have escaped detection. Flanders virus is an unclassified member
of the family _Rhabdoviridae_, which has been isolated from mosquitoes
throughout the USA, Canada, and Mexico. It is not known to be
associated with any animal, or human, disease. It is not related to
Jamestown Canyon virus, which belongs to the family _Bunyaviridae_.]
--------------
[3]
Date: Sun 8 Aug 2004
From: Clarence J. Peters <cjpeters@utmb.edu>
Source: ProMED-mail  ID 20040809.2197
VIRAL DIAGNOSTICS, COST-BENEFIT CONSIDERATIONS
I do not believe that a proper cost-benefit analysis has ever been done
for viral diagnostics. The ability to have a definite diagnosis
discourages the unnecessary use of antibiotics (particularly notablein
respiratory infections), and, can prevent hospitalization (particularly
in CNS disease). A definite diagnosis results in direct cost-savings
and could be a powerful weapon against the overuse of antibiotics and
thesubsequent incalculable human, and economic, costs resulting from
the loss of effective antibiotics.
An often quoted reason for not testing for viral infections is that
"there is no therapy." This is an interesting "catch 22." The reasoning
seems to be: if we can't treat it, why diagnose it? And, if we can't
diagnose it, why worry about developing treatment?
More to the point of this ProMED-mail submission is the long-recognized
phenomenon that there is a peak in summer encephalitis, without an
identified etiologic diagnosis, and, that this peak exactly mimics that
of diagnosed mosquito-borne encephalitis. I 1st saw this written up in
an MMWR from CDC VBDB in the late 1970's, and the observations were
repeated in the 1st year of the West Nile epidemic in New York, with
more undiagnosed cases than West Nile cases during that summer. It is
not clear to me whether the undiagnosed cases in these 2 reports result
from poor patient samples, insensitivity of current tests, circulation
of unrecognized agents not in our current test inventory, or some
combination. The most recent re-visit of this phenomenon that I have
seen is the recent EID article (Trevejo, 10:1442, August 2004). This
study did not examine the efficacy of virologic diagnosis but did
provide documentation of the low proportion of cases reported, the
large proportion of undiagnosed cases, and indirect evidence for
arbovirus participation.
The undiagnosed fraction of cases is a challenge and is also a shame
for a society that supposedly has such an advanced medical system. It
may also be relevant to the other ProMED-mail posting on Flanders virus
[ref. (04) below]. Another supposedly non-pathogenic rhabdovirus,
Chandipura virus, has recently been suggested as a cause of
encephalitis in SW Asia [see refs. below].
[ProMED Moderator JW Comments: I can relate 2 personal experiences.
During my time at CDC´s dengue lab in Puerto Rico from 1975-80, there
were dengue outbreaks every year.  We were never able to confirm more
than 50 percent of those clinically diagnosed cases in the lab.  Some
of this was due to the serum specimens not being in good condition or
not having been taken soon enough after onset, but as the
dengue season was the rainy season and therefore also the influenza
season, we attributed the other 50 percent to flu.  In a review of 2963
patients with signs of infections of the central nervous system in New
York State in 1966-1977, arboviruses were found to be the confirmed or
presumptive etiologic agents in only 60 patients. Those detected were
California encephalitis, Powassan, St. Louis encephalitis & eastern
equine encephalitis viruses. Ref: Deibel R, Srihongse S, Woodall JP
(1979).  Arboviruses in New York State: an attempt to determine the
role of arboviruses in patients with viral encephalitis and meningitis.
  Am J Trop Med Hyg. 1979 May;28(3):577-82.]
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