The Outbreak of West Nile Virus Infection in the New York City Area in 1999
Denis Nash, Ph.D., M.P.H., Farzad Mostashari, M.D., M.S.P.H., Annie Fine, M.D., James Miller, M.D., M.P.H., Daniel O'Leary, D.V.M., Kristy Murray, D.V.M., Ada Huang, M.D., Amy Rosenberg, M.D., Abby Greenberg, M.D., Margaret Sherman, R.N., Susan Wong, Ph.D., Grant L. Campbell, M.D., Ph.D., John T. Roehrig, Ph.D., Duane J. Gubler, Sc.D., Wun-Ju Shieh, M.D., M.P.H., Ph.D., Sherif Zaki, M.D., Ph.D., Perry Smith, M.D., Marcelle Layton, M.D., for the 1999 West Nile Outbreak Response Working Group
Background In late August 1999, an unusual cluster of casesof meningoencephalitis associated with muscle weakness was reportedto the New York City Department of Health. The initial epidemiologicand environmental investigations suggested an arboviral cause.
Methods Active surveillance was implemented to identify patientshospitalized with viral encephalitis and meningitis. Cerebrospinalfluid, serum, and tissue specimens from patients with suspectedcases underwent serologic and viral testing for evidence ofarboviral infection.
Results Outbreak surveillance identified 59 patients who werehospitalized with West Nile virus infection in the New YorkCity area during August and September of 1999. The median ageof these patients was 71 years (range, 5 to 90). The overallattack rate of clinical West Nile virus infection was at least6.5 cases per million population, and it increased sharply withage. Most of the patients (63 percent) had clinical signs ofencephalitis; seven patients died (12 percent). Muscle weaknesswas documented in 27 percent of the patients and flaccid paralysisin 10 percent; in all of the latter, nerve conduction studiesindicated an axonal polyneuropathy. An age of 75 years or olderwas an independent risk factor for death (relative risk adjustedfor the presence or absence of diabetes mellitus, 8.5; 95 percentconfidence interval, 1.2 to 59.1), as was the presence of diabetesmellitus (age-adjusted relative risk, 5.1; 95 percent confidenceinterval, 1.5 to 17.3).
Conclusions This outbreak of West Nile meningoencephalitis inthe New York City metropolitan area represents the first timethis virus has been detected in the Western Hemisphere. Giventhe subsequent rapid spread of the virus, physicians along theeastern seaboard of the United States should consider West Nilevirus infection in the differential diagnosis of encephalitisand viral meningitis during the summer months, especially inolder patients and in those with muscle weakness.
Source Information
From the Communicable Disease Program, New York City Department of Health, New York (D.N., F.M., A.F., J.M., M.L.); the Epidemic Intelligence Service, Epidemiology Program Office, Division of Applied Public Health Training, State Branch (D.N., F.M.), and the Division of Bioterrorism Preparedness (K.M.), Centers for Disease Control and Prevention, Atlanta; the Division of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, Colo. (D.O.); the Westchester County Department of Health, New Rochelle, N.Y. (A.H., A.R.); the Nassau County Department of Health, Mineola, N.Y. (A.G., M.S.); and the New York State Department of Health, Albany (S.W.).
Other authors were Grant L. Campbell, M.D., Ph.D., John T. Roehrig, Ph.D., and Duane J. Gubler, Sc.D. (Centers for Disease Control and Prevention, Fort Collins, Colo.); Wun-Ju Shieh, M.D., M.P.H., Ph.D., and Sherif Zaki, M.D., Ph.D. (Centers for Disease Control and Prevention, Atlanta); and Perry Smith, M.D. (New York State Department of Health, Albany).
Address reprint requests to Dr. Nash at the New York City Department of Health, HIV/AIDS Surveillance Program, 346 Broadway, Rm. 706, New York, NY 10013, or at dnash{at}health.nyc.gov.
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