The prevalence of Arbovirus (arthropod-borne virus) infections is increasing worldwide. Recently, new clusters of autochthonous cases have been reported in countries with temperate climates where the competent vector is present. This scenario represents a new threat for transfusion medicine.CHIKV has been a significant public health concern in Asian and African countries, where most epidemics occurred in the 1960s and 1990s, and is newly  emerging in Middle East, Pacific, American, and European countries. Exactly 10 years after the first European outbreak of CHIKV, the virus has emerged again in Italy where the competent vector (Aedes albopictus) is present

Franchini, Massimo

Liumbruno, Giancarlo M.

Marano, Giuseppe

Masiello, Francesca

Pati, Ilaria

Pupella, Simonetta

Vaglio, Stefania

Velati, Claudio

English

Archivio della ricerca- Università di Roma La Sapienza

489Blood Transfus 2017; 15: 489-90  DOI 10.2450/2017.0215-17© SIMTI Servizi SrlE਄ਉਔਏ਒ਉਁ਌Ten years since the last Chikungunya virus outbreak in Italy: history repeats itself Giuseppe Marano1, Simonetta Pupella1, Ilaria Pati1,2, Francesca Masiello1, Massimo Franchini1,3, Stefania Vaglio1,4, Claudio Velati1,5, Giancarlo M. Liumbruno11Italian National Blood Centre, National Institute of Health, Rome; 2Department of Biosciences, Biotechnologies and Biopharmaceutics, "A. Moro" University of Bari, Bari; 3Department of Haematology and Transfusion Medicine, "Carlo Poma" Hospital, Mantua; 4Department of Clinical and Molecular Medicine, "Sapienza" University of Rome, Rome; 5Italian Society of Transfusion Medicine and Immunohaematology, Rome, ItalyThe prevalence of Arbovirus (arthropod-borne virus) infections is increasing worldwide1. Recently, new clusters of autochthonous cases have been reported in countries with temperate climates where the competent vector is present2. This scenario represents a new threat for transfusion medicine3,4. The recent spread of Zika virus, new Dengue outbreaks in previously infection-naïve areas, and the stable seasonal presence of West Nile virus in Europe, teach us that the risk of virus outbreaks is never far away5-9. Chikungunya virus (CHIKV) is an Arbovirus, with a single-stranded RNA genome, belonging to the Alphavirus genus of the Togaviridae family, transmitted to humans by the bites of infected female mosquitoes (Aedes aegypti and Aedes albopictus). The onset of symptoms (fever frequently coupled with joint and muscle pain, headache, nausea, fatigue and rash) usually occurs between 4 and 8 days after the bite of an infected mosquito10,11. Severe clinical complications are very rare and most people fully recover in 3 to 10 days12,13. About 85% of cases are symptomatic14, which is a higher proportion than for other Arbovirus infections.CHIKV has been a significant public health concern in Asian and African countries, where most epidemics occurred in the 1960s and 1990s, and is newly emerging in Middle East, Pacific, American, and European countries4. Exactly 10 years after the first European outbreak of CHIKV, the virus has emerged again in Italy where the competent vector (Aedes albopictus) is present. The first outbreak was reported in the Emilia Romagna region during the summer of 20072,15,16 and involved the provinces of Ravenna, Forlì-Cesena, Bologna and Rimini, resulting in 217 confirmed out of 337 suspected cases. At that time, an active surveillance system including massive vector control actions and active case finding was implemented16. Laboratory investigations of suspected cases were performed through serology and in-house polymerase chain reaction analyses.  Measures for blood safety, in the absence of an authorised CHIKV test for the biological qualification of blood components, were based on blood donation interruption in the affected areas from September to October 2007 and on a 21-day deferral for donors who stayed, even for a short time, in those areas. Furthermore, the regional blood authority in cooperation with the National Blood Centre implemented an emergency blood supply plan in order to guarantee patients' transfusion needs in the Emilia-Romagna region. When the outbreak started to decline, the measures were gradually discontinued based on risk assessment results16. Blood collection restarted in the affected areas when the residual risk of collecting a viraemic donation was equal to or lower than that of transfusion transmitted hepatitis B virus (1:380,000, as estimated in Italy in 2007).In September 2017, new autochthonous cases of CHIKV infection were identified in Italy. Two different clusters occurred in two municipalities 60 kilometres apart - Anzio and Rome - in the Latium region. The identification of CHIKV cases in Rome, among family members without a history of travel to endemic countries or to Anzio, suggested an extension of the outbreak through a secondary vector-borne transmission focus. The regional health authorities immediately started massive vector control measures in and around the affected areas, active case finding and laboratory investigations of suspected cases. Preventive blood safety measures were immediately introduced following a risk-benefit evaluation which took into account the yearly consolidated need of red blood cells in Latium (about 30,000 units), which is supplied by other Italian regions, and the fact that the interruption of donations in the whole municipality of Rome (4 million inhabitants) would have had a massive impact on the regional blood inventory, national self-sufficiency and the local health system, and that the spread of infection (measured as the number of confirmed cases) is still relatively limited.Therefore, the following local measures were shared with the regional health authorities and adopted in Latium: (i) interruption of blood collection in the affected local health district of the Rome municipality All rights reserved - For personal use only No other use without premission© SIMTI Servizi Srl490Marano G et alBlood Transfus 2017; 15: 489-90  DOI 10.2450/2017.0215-17(1.3 million inhabitants) and in the municipality of Anzio (around 54,000 inhabitants); (ii) application of a 5-day quarantine for red blood cells collected from donors with a history of travel in the municipality of Anzio or in the affected district of Rome; (iii) reinforcement of donor clinical assessment; and (iv) mandatory post-donation information for donors who travelled in the affected areas and for all donors resident in the Latium region. Collection of plasma for fractionation is allowed as well as that of platelets and plasma for clinical use, provided pathogen inactivation is used.The national measures are based on a 28-day deferral of donors who stayed, even for a short time, in the municipalities of Anzio and Rome, but collection of plasma for fractionation is allowed. Donors diagnosed with CHIKV infection are deferred for 4 weeks after the resolution of symptoms. At the same time, the National Blood Centre activated a national emergency blood supply plan, which in the first 10 days allowed more than 2,500 red blood cell units to be sent to Latium from other Italian regions. In addition, all regions were invited to apply the national guidelines for the implementation of Patient Blood Management17-20.At the time of the submission of this editorial, the epidemiological investigation carried out by the regional reference laboratory for Arboviruses and the regional health authorities had confirmed 102 cases, but the investigation is still underway. Preventive blood safety measures will, therefore, be adapted on the basis of the results of the above-mentioned investigation and according to the geographical distribution of new confirmed CHIKV cases. Blood collection in the affected areas will gradually restart, based on the estimate of the residual risk of CHIKV transmission through blood transfusion, when available data show a decrease in the number of cases or as soon as a test for the biological qualification of blood components is validated and authorised.Disclosure of conflicts of interest GML is the Editor-in-Chief of Blood Transfusion and this manuscript has undergone additional external review as a result. The other Authors declare no conflicts of interest.References1) Weaver SC, Reisen WK. Present and future arboviral threats. Antiviral Res 2010; 85: 328-45. 2) Rezza R, Nicoletti L, Angelini R, et al. Infection with chikungunya virus in Italy: an outbreak in a temperate region. Lancet 2007; 30: 1840-6.3) Musso D, Aubry M, Broult J, et al. Zika virus: new emergencies, potential for severe complications, and prevention of transfusion-transmitted Zika fever in the context of co-circulation of arboviruses. Blood Transfus 2017; 15: 272-3.4) Petersen LR, Busch MP. Transfusion-transmitted arboviruses. Vox Sang 2010; 98: 495-503.5) Franchini M, Velati C. Blood safety and zoonotic emerging pathogens: now it's the turn of Zika virus! Blood Transfus 2016; 14: 93-4. 6) Marano G, Pupella S, Vaglio S, et al. Zika virus and the never-ending story of emerging pathogens and transfusion medicine. Blood Transfus 2016; 14: 95-100. 7) Musso D, Nilles EJ, Cao-Lormeau VM. Rapid spread of emerging Zika virus in the Pacific area. Clin Microbiol Infect 2014; 20: 595-6.8) Ministero della Salute Italiana. [Surveillance of human cases of Chikungunya, Dengue, West Nile disease and other arboviruses and assessing the risk of transmission in Italy 2015]. Ministero della Salute Italiana: Rome; June 2015. Available at: http://www.epicentro.iss.it/problemi/westNile/pdf/Circolare_arbovirosi_2015.pdf. Accessed on 25/09/2017. [In Italian.]9) Pisani G, Cristiano K, Pupella S, et al. West Nile Virus in Europe and safety of blood transfusion. Transfus Med Hemother 2016; 43: 158-67.10) Naowarat S, Tang IM. Transmission model of chikungunya fever in the presence of two species of aedes mosquitoes. Am J Appl Sci 2013; 10: 449-59. 11) Solignat M, Gay B, Higgs S, et al. Replication cycle of chikungunya: a re-emerging arbovirus. Virol J 2009; 393: 183-97.12) Coffey LL, Failloux A, Weaver SC. Chikungunya virus-vector interactions. Viruses 2014; 6: 4628-63.13) Schilte C, Staikovsky F, Couderc T, et al. Chikungunya virus-associated long-term arthralgia: a 36-month prospective longitudinal study. PLoS Negl Trop Dis 2013; 7: e2137. 14) Appassakij H, Khuntikij P, Kemapunmanus M, et al. Viremic profiles in asymptomatic and symptomatic chikungunya fever: a blood transfusion threat? Transfusion 2013; 53: 2567-74.15) Moro ML, Gagliotti C, Silvi G, et al. Chikungunya Virus in North-Eastern Italy: a seroprevalence survey. Am J Trop Med Hyg 2010; 82: 508-11.16) Liumbruno GM, Calteri D, Petropulacos K, et al. The chikungunya epidemic in Italy and its repercussion on the blood system. Blood Transfus 2008; 6: 199-210.17) Guerra R, Velati C, Liumbruno GM, Grazzini G. Patient Blood Management in Italy. Blood Transfus 2016; 14: 1-2. 18) Vaglio S, Prisco D, Biancofiore G, et al. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. Blood Transfus 2016; 14: 23-65. 19) Franchini M, Muñoz M. Towards the implementation of patient blood management across Europe. Blood Transfus 2017; 15: 292-3. 20) Vaglio S, Gentili S, Marano G, et al. The Italian Regulatory Guidelines for the implementation of Patient Blood Management. Blood Transfus 2017; 15: 325-8. Correspondence: Giancarlo Maria LiumbrunoItalian National Blood CentreVia Giano della Bella 2700162 Rome, Italye-mail: giancarlo.liumbruno@iss.itAll rights reserved - For personal use only No other use without premission©SIMTI Servizi Srl

Ten years since the last Chikungunya virus outbreak in Italy. History repeats itself

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Ten years since the last Chikungunya virus outbreak in Italy. History repeats itself

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