Technical Note 1 The Epidemiology of Mosquito-borne Diseases Prepared by Dr L. Molineaux

Technical Note 1 The Epidemiology of Mosquito-borne Diseases Prepared by Dr L. Molineaux 1 Introduction Epidemiology is the science that describes and explains the distribution of disease in human populations: who has the disease (or the infection), how seriously, and when, where, and why? This note reviews the principles of the epidemiology of mosquito-borne diseases, and relates them to control, particularly to environmental control. The presentation is intentionally schematic. Any reader wanting to know more about the epidemiological principles is referred to Epidemiology and Control of Vector-borne Diseuse, U.S. Department of Health, Education, and Welfare, The Public Health Service, and Communicable Disease Control. As this note is mainly concerned with environmental control and is primarily addressed to engineers, the emphasis is on infection rather than on disease. Certain control methods (e.g. the treatment of patients suffering from malaria) can have a major impact on the prevalence and severity of a disease - and on mortality - but will have little effect on the incidence and prevalence of infection. 2 The Factors Involved (Qualitative Epidemiology) 2.1 The Populations Involved The parasite population is the population of mosquito-borne parasitic organisms responsible for human disease. Included in that population are viruses, protozoa, and helminths. The parasite population circulates in the human population, in one or more mosquito populations, and, in certain cases, also in one or more animal populations. There are three main types of association. These are illustrated in Figure 1. The species primarily responsible for maintaining the parasitic population is called the reservoir. In Type 1, the reservoir is man; in Types 2 and 3, the reservoir is animal. (The dotted arrows in Type 2 indicate that man is usually not a reservoir for the animal disease.) In Type 3, man may become infected (and ill) but not infective; he is then known as a dead-end host. In addition to the horizontal transmission routes in Figure 1, certain infections are also transmitted vertically : from female parent to offspring, either in man (as with congenital malaria) or in the mosquito (as with certain group viruses). Implications for Control The control strategy adopted should take into account the various populations involved and their degree of association. If, for example, an animal reservoir exists and is ignored, control efforts may fail. 263

Malaria Bancroftian Filariasis Periodic Malayan filariasis Dengue? Chikungunya? TYPE 2 human population mosquito population(s) human - mosquito population -----$opulation(s) Yellow fever Subperiodic Malayan filariasis pop~lation(s)----~population(s) TYPE 3 Western equine encephalitis Eastern equine encephalitis St Louis encephalitis Venezuelan equine encephalitis Japan B encephalitis West Nile fever Wesselbron virus California encephalitis group human mosquito population -population(s) animal population(s) Figure 1 The three main types of associations between populations involved in the transmission of mosquito-borne infections 2.2 The Infection in the Human Host Multiplication and/or Development The parasitic agents fall into three groups. They may: - Multiply only (as in virus diseases); - Develop only (as in filariasis); - Multiply and develop (as in malaria). Immunity and Superinfection Viruses typically produce rapid, complete, and life-long immunity, with no superinfection (a second infection in the wake of the first). In malaria, immunity develops slowly and progressively as a result of repeated infections (and superinfections), and is always partial and reversible. Less is known about immunity to filariasis, but it is likely that superinfection is common and that, because the worms are long-lived, there is an accumulation of parasites. Immunity may develop even more slowly than with malaria. Disease Mosquito-borne parasitic agents may produce acute or chronic illness, or both. If 264 t

I one s aim is to control disease by controlling its transmission, it may be useful to distinguish between illness (acute or chronic) resulting from the first infection and illness resulting from repeated infections. The latter could result in an accumulation of parasites or in immunopathology (a lowered resistance to disease), or both. With the possible exception of dengue, mosquito-borne viruses cause infection and disease through the first contact. In dengue, the initial infection may not give rise to any apparent disease, but creates an immunopathological reaction. Upon later reinfections, the immunopathology may give the chronic disease. Dengue is mentioned as a possible exception because some of its manifestations are attributed to immunopathology - a theory that is not universally accepted. In most non-immunes, the first infection of malaria typically produces acute illness (life-threatening in the case of P. fulcipurum), whereas repeated infections produce relatively mild chronic illness in most persons, and, for reasons not yet well understood, severe chronic illness in a few. Filariasis produces acute illness, but its most serious consequences (elephantiasis, hydrocoele) result from prolonged exposure, although, again for reasons not yet well understood, only in certain persons. Implications for control If disease results mainly from repeated contact, any reduction in transmission can only result in a decrease in disease. If disease results mainly from the first contact, two scenarios are possible: - If man is not the reservoir (in which case the immunity of the human population is usually low), any reduction in transmission will again result in a decrease in disease; - If man is the reservoir (in which case the immunity of the human population may be high, as it is in areas of intense malaria transmission), a partial reduction in transmission may displace morbidity (and any resulting mortality) towards older age-groups (from infants to children to adolescents to adults). This may or may not be socially acceptable. With malaria, this very issue has been the subject of much controversy. Really hard data are not available, for understandable reasons, mainly ethical, but one should be aware of the problem and be ready to consider remedial measures (e.g. increasing the effectiveness of the control of transmission and/or of the diagnosis and treatment of cases) or an even more radical change in strategy. 2.3 The Infection in the Mosquito The reader is reminded that only adult female mosquitoes transmit diseases to man and animals. Multiplication and/or Development What has been said about infection in the human host can be repeated here. The para- 265

sitic agents will multiply only, develop only, or multiply and develop. In all cases, an incubation period is required before the mosquito becomes infective. Mosquitoes are poikilothermic (i.e. they only multiply and/or develop within a certain range of temperature). Within that range, the incubation period varies inversely with temperature. Mosquito Survival In the mosquito, the infection s incubation period is typically of the same order of magnitude as its life expectancy. Most infected mosquitoes do not survive long enough to become infective. The infection itself may shorten the life of the mosquito, although this is not known with certainty and, in most cases, is probably of minor epidemiological importance. 2.4 Entomological Factors of Transmission The rate of transmission depends on the following factors: a) The number of adult female mosquitoes; this in turn depends on their rate of emergence and their life expectancy; b) The frequency with which they feed; c) The proportion of bloodmeals taken from the relevant hosts (e.g. man in the case of malaria). This depends on genetically conditioned preferences and on the relative availability and accessibility of alternative hosts. Accessibility is affected by environmental factors (e.g. types of human and animal shelters) and by behavioural factors, such as: - Does the vector bite by day or by night? - Does it prefer to bite indoors or out? - Where are men and animals when the vector bites them? d) The length of the infection s incubation period in the mosquito; e) The life expectancy of the mosquito, which affects both the proportion of mosquitoes surviving the incubation period, and the number of infections they distribute after becoming infective. Implications for Control Residual spraying reduces Factors a) and e). Other vector control methods reduce Factor a). Research is currently exploring the possibility of replacing a vector population with a physiologically insusceptible population. Factor c) can be reduced by decreasing the accessibility of man (e.g. with screened houses, bed-nets, repellents, and/or by zooprophylaxis, i.e. increasing the availability and accessibility of alternative sources of blood). Some of these measures are adapted to night-biters, either exclusively (bed-nets) or largely (screened houses). 266

2.5 Other Environmental Factors The ways in which the environment and the manipulation of it affect the emergence of mosquitoes are covered elsewhere in this book. Here, a few points only are considered. Temperature has multiple effects. Within tolerated limits, a rise in temperature: - Accelerates the development of the aquatic stages; - Shortens the incubation period in the vector; - Increases the vector s frequency of feeding; - Shortens the vector s life expectancy, although probably to a lesser extent than the incubation period is shortened. This means that the fraction surviving the incubation period probably increases. That, at least, was found to be true in the single case in which this matter was explicitly inveitigated, namely in a study of malaria transmitted by A. maculipennis in the U.S.S.R. The air s saturation deficit may also inversely affect the vector s life expectancy. The availability of shelters other than houses (e.g. vegetation) may reduce the vector s endophily. Implications for Control The effect of temperature on the development of the aquatic stages is relevant when the frequency of larvicide applications is being decided. The other effects of temperature are relevant when one is evaluating the intensity of transmission, which in turn is relevant when control strategies and objectives are being selected. 3 The Dynamics of Transmission (Quantitative Epidemiology) The environmental control of mosquito-borne disease, alone or in combination with other control methods, may have the following objectives: - To prevent epidemics; - To eradicate an endemic disease; - To reduce an endemic disease to an acceptable level. When emergency measures are called for to control an on-going epidemic, environmental control will only be of minor importance, but in achieving any of the above objectives, it - and quantitative epidemiology - have definite roles to play. 3.1 The Basic Reproduction Rate (R) The basic reproduction rate (R) is the number of secondary cases (infections) that result from the introduction of an infective case into a population of susceptibles. R is the maximum reproduction rate that is theoretically possible in a given situation. The actual reproduction rate is reduced below R through the effect of immunity. This 267

holds true whether immunity is complete, as in viral diseases, or incomplete, as in malaria. In a stable situation, the actual reproduction rate is equal to one. A formula for the basic reproduction rate of a vector-borne disease in a vertebrate population (e.g. man) is given in Equation 1 (after McDonald 1957, The Epidemiology and Control of Malaria, Oxford University Press) where: r 1 - r m a ma P n P" -log,p = the vector's life expectancy (days), independent of age; b' b = the rate at which a non-immune infective recovers from infectivity; = the infective period (days) in man; = the number of vectors per man; = the number of bloodmeals taken on man per vector per day; = the number of vector bites per man per day; = the proportion of vectors surviving 1 day (assuming the mortality of vectors to be independent of age and infection); = the incubation period (days) in the vector; = the proportion of vectors surviving the incubation period; = the proportion of bites on infective persons which result in infection of the vectors; = the proportion of bites by infective vectors on non-immune persons which result in infection of the persons. Remark MacDonald's formula is identical to the above, except for the factor b', which we have added. 3.2.The Vectorial Capacity If we remove r from R, we obtain a 'daily basic reproduction rate' or a 'daily (effective) contact rate'. Let us call that quantity 'the vectorial capacity' and denote it by C. We then have ma2bb'pn C C= and R = - -hlp 2 Remark When several vector and vertebrate populations are involved, there will be a distinct contact rate (vectorial capacity) for each pair of vector and vertebrate species. 268

3.3 Threshold: the Critical Vectorial Capacity and the Critical Mosquito Density There is a risk of an epidemic only if R > 1 (i.e. if C > r), and an infection can remain endemic only if R > 1 (i.e. if C > r). A further condition for the infection to remain endemic is an adequate supply of susceptibles, which depends on population size, birth rate, and type of immunity produced. An infection like malaria, which produces only a slow, progressive, incomplete, and reversible immunity, can maintain itself in a much smaller population than can viral infections, which produce a rapid, complete, and irreversible immunity. Critical Vectorial Capacity The critical vectorial capacity (C*), below which there is no risk of an epidemic, and below which the infection cannot remain endemic, is C* = r The critical vectorial capacity is a characteristic of the parasite; it is higher for infections with a large r (i.e. a short infectious period). Critical Vector Density For given r, a, b, b', p, and n, there is a critical value of m (m*) (i.e. a critical vector density), namely the value that satisfies There is also a critical value of 'ma', the man-biting rate, namely (ma)* = -r logcp ~ abb'p" Figure 2, based on Equation 3, shows the critical density for different recovery rates as a function of a2bb'p" -logcp which can be considered an index of vector efficiency. Environmental control may reduce vector density and/or man-vector contact. The concept of critical vector density, illustrated in Figure 2, is useful when a control program is being planned, even though the estimates of the parameters involve a large measure of uncertainty. (4) l 269

critical vector density in in index of vector efficiency a2bblp -hep Figure 2 The critical density as a function of an index of vector efficiency for different recovery rates Relevance for Control If the objective is to eradicate or prevent epidemics, we want R < 1 or C < r. Note that in certain mosquito-borne infections, the actual vectorial capacity can be hundreds (perhaps even thousands) of times larger than the critical value. We therefore need estimates of both the natural vectorial capacity and its expected reduction after control measures have been applied. If fully protective immunization is possible and if X = the proportion of the population that is immunized, the interruption of transmission requires or (I-X)R < 1 or(1-x)c < r (1-X)(x) (a2)(bb ) < r -logep This equation helps in understanding the impact and synergism of broad classes of control methods: - Immunization reduces (1-X); - Vector control reduces (-Ei:p); ~ residual ods of vector control only reduce m; - The reduction of man-vector contact reduces (a2); - Drugs increase r. 270 (5) spraying reduces m and p; the other meth-

3.4 The Relationship between Vectorial Capacity and the Endemic Level of Malaria This section deals specifically with malaria, because it is for malaria that this aspect of quantitative epidemiology has been best developed and is most relevant. Figure 3 illustrates the central place occupied by the vectorial capacity in the epidemiology of malaria. The endemic level (the amount of malaria in a population) is determined by certain intrinsic (genetic) characteristics of man and parasite - characteristics that are relatively stable in time and space - and by the vectorial capacity - which is unstable and can vary greatly and rapidly in time and space. Variations in vectorial capacity are thus mainly responsible for the differences between different malaria situations, and for seasonal and other temporal changes in a particular malaria situation. The vectorial capacity is determined by certain intrinsic (genetic) characteristics of the vectors, which are relatively stable in a given place, but can vary greatly between places, between different anopheline species, and sometimes also within a single species. The environment, which is unstable in time and space, affects the vectorial capacity. Through natural selection (suggested by the dotted arrows in Figure 3), the environment slowly affects the genetics of man, vectors, and parasites. The relationship between the vectorial capacity and the endemic level is shown in Figure 4, which has been derived from different mathematical models of the transmission of malaria. The figure shows the natural equilibrium endemic level, which corresponds, in the long run, to a given level of vectorial capacity. The main qualitative features of the relationship are independent of the model used and have been firmly established. They are: - There is a critical level of vectorial capacity below which malaria cannot maintain itself; - Above the critical level, the relationship is non-linear: In the lower range, a small difference in vectorial capacity produces a large difference in endemic level; In the higher range, even a large difference in vectorial capacity produces little or no difference in endemic level. (Note that the horizontal scale is logarithmic.) This saturation effect is due to the finite size of the human population and to I I I genetics vectorial endemic capacity level I L- t Figure 3 The central place of the vectorial capacity in the epidemiology of malaria 27 I

proportion positive for P. falcioarum 2 4 6810-1 2 4 6810 2 4 6810 2 4,68102 vectorial capacity Figure 4 Yearly average crude parasite rate as a function of yearly avcragc vectorial capacity (from Dietz et al. 1974, WHO Bulletin 50: 347-357) immunity. Immunity has been taken into account in the model of Dietz et al., but not in the other models of Figure 4; they therefore produce endemic levels of up to 100 per cent. Implications for Control The implications for control are obvious and important. In the model of Dietz et al., for example, a reduction in vectorial capacity from 20 to 2 would only reduce the prevalence of (patent) P. fulcipurum parasitaemia from 59 to 51 per cent. A decrease in vectorial capacity from 2 to 0.2 would reduce the prevalence of malaria from 51 to 45 per cent. A decrease in vectorial capacity from 0.2 to 0.02 would reduce prevalence from 45 per cent to zero.. Even though the actual figures are questionable (because of assumptions made and measurement errors), there is no doubt about the general relationship. Historically, the existence of a threshold had already been demonstrated by Ross, and the implications of the non-linear relationship for control were explicitly deduced and stressed by Moshkovsky (1967, WHO Bulletin 36: 992-996). The long-term natural equilibrium between vectorial capacity and endemic level, as considered here, is particularly relevant for environmental management, because environmental management will bring permanent changes that will lead to a permanent reduction in vectorial capacity and a lower endemic level. 3.5 Integrated Control: Synergism between Methods Figure 5 illustrates the synergism between immunization, reduction of the vectorial 272

y=prevalence of infection Figure 5 Impact of a reduction in the vectorial capacity, an increase in the recovery rate, and immunization -alone or in combination - on a hypothetical vector-borne infection capacity, and an increase in the recovery rate. In this hypothetical case, none of the three methods alone (employed with moderate effectiveness) would result in eradication; neither would any of the three combinations of two of the three measures; but the three methods combined would achieve eradication. At the present time, however, there is no mosquito-borne disease on which all three measures could be employed. The figure involves some rather crude assumptions, particularly those about the homogeneity of the human population and its contact with vectors, and about immunization and drug treatment. Even so, the figure illustrates an important general principle: immunity against an infection is produced by immunization (malaria and sporozoite vaccins). In the simplest malaria model (i.e. the one-step reversible catalytic model, Ross s single-equation model), the-equilibrium relationship between the variables is y = (1 -X)[ 1 -r/(r-x)c] I- Curve I represents the original relationship between y and C for r = 0.05 and X = O. Curves 11,111, and IV represent the new relationships that result, respectively, from doubling the recovery rate, protecting half the population by immunization, or both. Point a represents the initial prevalence for C = 2. Points b to h represent the impact of three interventions, alone or in combination, as follows: -_ Points Interventions a b C d e f g h 10-fold reduction of C - + - - + - Doubling r - - + - + - Protecting 50% by vaccination - - - + - + + + 273