West Nile Fever Outbreak, Israel, 2000: Epidemiologic Aspects

Abstract

West Nile VirusIn early August 2000, infectious disease specialists in hospitals in central Israel noted an increasing number of elderly patients admitted for encephalitis.By mid-August, when several blood and cerebrospinal fluid (CSF) samples tested positive for antibodies for West Nile (WN) virus, an outbreak was suspected.Eventually a WN fever epidemic that affected the entire country was recognized.This article outlines the epidemiologic aspects of this WN fever epidemic; Chowers et al. (1) details the clinical characteristics.These are the first in-depth descriptions of an outbreak caused by WN virus involving an entire country. MethodsSerologic studies from blood and CSF were performed by one facility, the Central Virology Laboratory, Public Health Services, Israel Ministry of Health, at the Chaim Sheba Medical Center, Tel Hashomer.From August 1 to October 31, 2000, this laboratory reported 417 serologically confirmed cases of WN fever to the Epidemiology Department of the Israel Ministry of Health.These patients are the focus of our study.Basic demographic data, date of disease onset, and the patients' final outcome (alive or dead) were available from the files of the Department of Epidemiology, Israel Ministry of Health, and health district offices around the country.From early September 2000, infectious disease specialists in hospitals throughout Israel were asked to complete a detailed questionnaire on clinical, epidemiologic, and laboratory data for patients with WN virus at their hospitals.Information on the clinical presentation of the patients at ambulatory settings was obtained from the health district offices.Data on the Israeli population by age group, geographic distribution, and type of locality were retrieved from the Israeli Central Bureau of Statistics (2).Israel is divided into six major geographic districts (Jerusalem, Northern, Haifa, Center, Tel-Aviv, Southern), as well as the Judea, Samaria, and Gaza areas.The permanently inhabited places in Israel are divided into urban (>2,000 population) and rural (<2,000, even if not agricultural) localities.Diagnosis of WN fever was based on immunoglobulin M (IgM)-capture enzyme-linked immunosorbent assay (MAC-ELISA) in serum or CSF samples of patients.The assay, which was developed in the Central Virology Laboratory during 1999-2000, includes the following steps: a) binding of anti-human IgM to the ELISA plate; b) incubation with the patient's serum or CSF sample (dilutions of 1:100 and 1:2,000 for serum and 1:10 and 1:100 for CSF); c) incubation with WN virus antigen prepared from Vero cells infected with an Israeli gull isolate from 1999 (Banet C, manuscript in prep.);d) incubation with a mouse anti-flavivirus monoclonal antibody (JCU/KUN/2B2, cat.no.01-031-02, TropBio Pty Queensland, Australia); and e) incubation with peroxidaseconjugated goat anti-mouse antibody (cat.no.115-035-071, Jackson ImmunoResearch Laboratories, West Grove, PA) and substrate.Cross-reactivity with other flaviviruses was not thoroughly evaluated; however, no other endemic crossreacting flavivirus is known to infect humans in Israel.

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