### Puerto Rico West Nile Response Plan

Introduction

This report describes the response plan that th e Puerto Rico Department of Health (PRDOH), working in collaboration with the Centers for Disease Control and Prevention (CDC) and other state and federal agencies, has implemented to addr ess the potential arrival of West Nile virus (WNV) to Puerto Rico.

In 1999 West Nile virus was first detected in t he United States. Since then, the infection has repeated itself annually, spreading through the nati on from East to Southwest and being detected in 44 states and the District of Columbia. In 2002, it was responsible for infection in 4,156 humans of which 284 died. It also caused infection in 14,417 horses of which approximately 4,325 (30%) died; birds; and some other species including domestic species. Since 1999, there has also been evidence of WNV in Central Am erica and the Caribbean, mostly in animals. Evidence of local transmission has been docum ented in Mexico (horses), Cayman Island (one human case), Dominican Republic (antibodies in birds), Jamaica (antibodies in birds) and El Salvador (horses).

Even though most infections are clinically unappar ent, 1 out of 5 (20%) persons infected develop West Nile Fever, a sickness very similar to Dengue, and 1 out of 150 develop severe neurological sickness. The severe phase could present mening itis, altered mental state, severe muscular weakness, acute flaccid paralysis, and symptom s similar to those in Polio and Parkinson.

West Nile virus is a flavivirus transmitted primarily by the Culex pipiens mosquito, species commonly found throughout Puerto Rico. Because of the great possibility of WNV’s arrival to the Island, Puerto Rico’s Department of Health has organized a plan to address the issue to protect our citizens.

This plan describes:

• the surveillance systems to identify the virus in birds and mammals,

• the prevention, response, and contro l systems that will be implemented,

• the surveillance systems to i dentify the virus in mosquitoes,

• the active and passive surveillance sy stems for human West Nile virus cases,

• the electronic data collection and sharing among public, state, and federal agencies

• the public campaign for public education

The resources allocated in this effort, including plan, infrastructure, and communication network, will form a cohesive multi-agency approach to respond to other similar disease events. To implement this plan we will require the cooperat ion and participation of local, state and federal agencies, community organizations, and specially, t he general public. Working with connectivity, as a team, we will establish an early detection system that will minimize the risk of West Nile virus infection in humans and animals throughout the Island.

Surveillance

In Puerto Rico, WNV Animal Surve illance consists of laboratory testing of dead birds, birds in captivity, wild birds, sick and healthy horses, and canines. Human Surveillance consists of laboratory testing of patients with meningitis, ence phalitis, acute flaccid paralysis, and other Polio, Guillain-Barré and Parkinson-like syndromes.The main goal of these surveillance systems is to detect areas of local transmission. The data generated by these surveillance systems will be used to release recommendations for the prevention and control of the disease am ong animals and humans throughout the Island.

Animal Surveillance

Animal surveillance has proved to be an efficient way to identify promptly WNV infection through different regions of the United States. Dead bird surveillance has been the one with best results.

Birds

Dead bird surveillance

In United States, bird mortality and morbidit y due WNV has been documented during the past transmission seasons. Researchers have foun d that human cases are usually preceded by detection of birds dead due to WNV infection. The PRDOH, in collaboration with the CDC, has developed a dead bird surveillance system. Pers onnel from the PRDOH, CDC, United States Fish and Wildlife Service (USFWS), United States Department of Agriculture (USDA), Puerto Rico Department of Agricultur e (PRDA), the Department of Natural and Environmental Resources (DNRA) were encouraged to assist in the recolle ction and transportation of dead birds trough the island.

This surveillance system consists of the reco llection and transportation of dead birds to the Puerto Rico CDC - Dengue Branch Laboratory. As birds arrive to the laboratory, they will be tested for WNV infection. Samples will be collect ed by collaborating agencies and by the general public as well.

A press conference, lead by the Secretary of the PRDOH, will be held at the beginning of the peak of transmission season (August). In this conference, the general public will be advised to report and transport dead birds to collection sites located through the Island. Instructions for proper handling of the dead birds, location, and pho ne numbers of collection sites will be given in the press conference and published in national and regional newspapers. Instructions will be available at the PRDOH web page ( http://www.salud.gov.pr ), will be given when people report by phone, and will be released by press communicates as required.

Samples are transported by the Coordinator or by collaborator agencies. Carcasses will be tested for WNV (deep stick and PCR) by PRDOH personnel in a biosafety level 3 laboratory located at the Puerto Rico CDC-Dengue Branch.

Although all dead bird species will be collected thro ugh the Island, the laboratory will only accept fresh carcasses with no signs of decomposition. If the number of samples submitted exceeds the laboratory capabilities, restrictions will be set base d on location or specie type. After tests are conducted, results will be posted in the PRDO H web site and the CDC national database for arbovirus known as ARBONET.

Wild bird surveillance

Wild bird surveillance consists of testing blood samples collected from cowbirds ( Molothrus bonariensis ) captured by DNER as part of Yellow-sh ouldered Blackbird Recovery Program. Traps are placed in the municipalities of Lajas and Cabo Rojo. Every one or two weeks, traps are visited and captured birds are bled prior to euth anasia (performed by DNER). In addition, there is a collaborative agreement with the Smithsonian En vironmental Research Center and the KansasUniversity; these two instit utions will conduct serologi cal studies in wild bird s in different areas in the Island. Wild birds will be tested for WNV antibodies (HI).

Zoo

West Nile virus was first confirmed in a dead cr ow found in the Bronx Zoo in New York. Zoos used to monitor their animal collections very clos ely. The cause of death is usually investigated. In addition, deaths of wild birds in their facilitie s are also investigated, as these might have died from communicable diseases.

In Puerto Rico, Island’s zoos agreed to report and summit dead bird samples (collection or wild birds) to the PRDOH for testing. These sa mples will be transported to CDC-Dengue Branch by the Coordinator or collaborating agencies.

Equine surveillance

During 2002, more than 14,000 horses were report ed of developing WNV infection in the United States. Among those, about 30% (4,325) died or we re sacrificed. For this reason, in Puerto Rico, the general public, private veterinarians, USDA-Veterinary Services (USDA-VS) and the PRDA are submitting samples from sick equine s. Tests performed to sick horses’ samples include ELISA, PCR, PRNT and HI.

Healthy horses of different areas of the Island w ill be bled by collaborating veterinarians. As part of the equine surveillance, veterinarians will be ca lled to follow up on potent ial cases. Samples submitted will be tested for antibodies by HI and EL ISA. Equine samples are to be transported by the Coordinator or collaborating agencies to CDC-Dengue.

Canine

Canine surveillance

Studies conducted in the state of Nebraska by the Nebraska Game and Park Commission (NGPC) and the University of Nebraska Veterina ry Diagnostic Center (UNVDC) suggested that coyotes may serve as sentinels for WNV exposure. Using this information as a baseline, PRDOH decided to conduct a monthly serologic survey of wandering dogs in participating animal shelters. The shelters included this year are: Animal Control Solutions, Animal Control Center from San Juan, Animal Control Center from Caguas , Animal Control Center from Ponce, and Villa Michelle in Mayagüez. Blood samples acquired fr om dogs are to be collected by veterinary technicians or veterinaries and transported by the Coordinator or collaborating agencies to Puerto Rico CDC-Dengue Branch for further WNV testing. Canine samples are tested for antibodies by HI and ELISA.

Swine

Swine serum samples are being tested by Hemaglutinin Inhibition for WNV antibodies. Samples will be collected from different municipalities of the Island and will be prov ided by the USDA-VS. Samples are to be transported by the Coordinator or collaborating agencies to PR CDC-Dengue Branch for further WNV testing.

Mosquito

Mosquito surveillanceEven though mosquito surveillance has been conducted in the United States, in Puerto Rico it is not being conducted at this time. It will be consid ered when the virus is detected in the Island.

Human Surveillance

Taking into account the occurrence of WNV in the United States since 1999, Puerto Rico Department of Health has taken the initiative to begin establishing protocols to address such a threat.

Control and Prevention

Response strategies

Response strategies will be based on the potentia l of human infection in a particular region. PRDOH will work collaboratively with HAFI to implement strategies required. Right at this moment, Puerto Rico is situated in Response Level I.



### Response level Circumstances Response -Educational campaign -Enhanced passive human and bird surveillance -Consider adult mosquito surveillance, document species and distribution, lower lab testing priority -Active bird surveillance and equine surveillance -Human surveillance I No historical or current evidence of virus

-Consider local disease risk assessments -Enhanced educational campaign General public Provider community -Local environmental assessments -Local disease risk assessments -Active human (only county with historical evidence) and bird surveillance II Historical evidence of virus

-Adult mosquito surveillance and lab testing -Enhanced educational campaign General public Provider community -Active human, bird and equine surveillance III Current evidence of WNV presence in individual locations (virus isolation or evidence of infection) -Adult mosquito surveillance, lab testing

### -Adult mosquito control, ground application -Enhanced educational campaign General public Provider community -Active human, bird and equine surveillance -Adult mosquito surveillance, lab testing IV Current evidence of wide-spread WNV presence in multiple locations (virus isolation or evidence of infection)

-Adult mosquito control, ground application

Educational Campaign

Educational campaigns w ill be started. They will emphasize the ways in which mosquito bites can be avoided (by the use of protective clothing, use of repellents, installation of screens on windows and doors, and avoiding acti vities at dawn and dusk).

These campaigns will be performed in collaboration with municipal governments, CDC, private industries, and schools. Posters, flyers, and co loring books will be used as educative tools.

Mosquito Control with Non-Insecticide Methods

Citizens will be encouraged contribute in the prevention and co ntrol of a virtual epidemic. They will be instructed to remove standing water from pool covers, abandoned pool, rain gutters, and any vessel in their proper ty that can hold water. In addition, they will be advised to introduce fish into ponds and decorative lakes for larval control.

Municipal governments will be encouraged to maintain public areas free of tr ash, especially of those capable of collecting water. We will also ask for the appropriate maintenance of drainage.

Mosquito control through the use of insecticides Appendix 1. Document prepared by HAFI.

Communication plan

The objective of the communication plan is to keep citizens informed of the surveillance findings. If virus transmission is detected, residents will be notified and advised through press releases to avoid mosquito bites and to eliminate mosquito breeding areas in their vicinity.

All surveillance data and results will be posted in the PRDOH web page. This data will be regularly updated.

Acknowledgments

Entities that are collaborating in this plan are:

Carolina Animal Control Center Centers for Disease Control and Prevention Compañía de Parques NacionalesDepartment of Natural and Environmental Resources Fideicomiso de Conservación de Puerto Rico Humacao Animal Shelter Kansas University Ponce Animal Control Center Private Veterinarians and clinics Puerto Rico Department of Agriculture San Juan Animal Control Center Smithsonian Environmental Research Center Sociedad Ornitológica de Puerto Rico United States Department of Agriculture United States Fish and Wildlife Service Villa Michelle Animal Shelter in Mayagüez

Appendix I. HAFI’s WNV Response Plan

Appendix II. PRDOH WNV Response Plan