**2. Human MBDs national surveillance plan**

After the CHIKV outbreak in 2007 in Italy, a national plan on imported and autochthonous human vector-borne disease (including CHIKV, ZIKA, DENV and WNV) has been implemented and annually updated on the basis of the epidemiological changes-based evidences.

The plan has been annually revised to 2017 with minor changes except for the exclusion of WNV and USUV in 2016/2017 from the human plan, due to the birth of the WNV/USUV National integrated Plan.

Here, we summarize the main concepts.

donor, leaving areas with ongoing transmission of WNV and WNV Nucleic Acid Test (NAT), testing of all donations (peripheral blood, bone marrow and cord blood stem cell donations) generally from July to November [30] and coming from Provinces in which human cases of

The NAT screening approach changed in 2015 for five Northern Italian Regions (Piemonte, Lombardy, Friuli Venezia Giulia, Veneto and Emilia-Romagna) concerned by WNV circulation in previous years. These regions guaranteed an active standardized integrated entomologic and veterinary WNV surveillance from June to October. In addition to the notification of human cases, the date detection of WNV in mosquitoes and wild birds or detection of WNV-IgM antibodies in horses was introduced as new trigger criteria for the implementation

Since 2009, a total of 103 WNV positive samples in blood donors have been reported in

Comprehensive epidemiological, virological and entomological surveillance system is crucial for the timely detection of the spread of WNV, implementation of control measures and prevention of virus transmission in humans. Both national WNV veterinary and human surveillance plan have undergone further revisions year by year, in order to adapt to the seasonal

In 2016, the MoH has released a National WNV veterinary-entomological-human integrated Surveillance Plan. According to 'One-Health' approach, real-time cross-sectorial collaboration by Public and Veterinary Health Institutions is crucial to timely achieve and share information in WNV surveillance as a key to improve the management of WNV outbreaks and mitigate

The aim of the programme was to early detect WNV circulation, reducing the risk of infection

**1.** Veterinary surveillance: the Italian territory was subdivided into two distinct epidemio-

**a.** Endemic areas, where WNV was detected in the previous 2 years (mainly Regions of the Po river Valley, Sicilia e Sardegna islands): reinforcement of the virological screening in migratory and resident wild birds, mainly belonging to *Corvidae* genus. Alternatively,

**b.** Non-endemic areas (the remaining Italian Regions): serological testing of horses sera, in

**2.** Entomological surveillance: active mosquitoes fortnightly trapping during the epidemic season. Sampling sites selection was made according to risk factors for WNV cycle establishment: proximity to wetland areas, the presence of hosts, previous outbreaks. Moreover, a standardized approach was suggested, mapping provinces into equal quadrants (20 x 20 km), with at least one mosquito trap per quadrant. The aim was to establish seasonal

mosquito patterns and detect WNV in mosquito pools by virological screening.

WNND had been reported the previous year.

56 Current Topics in Tropical Emerging Diseases and Travel Medicine

evolution of the epidemiological scenario.

the risk of human transmission.

logical territories:

of WNV NAT testing for the screening of blood donors [31].

Northern Italy (Veneto, Lombardia and Emilia-Romagna Regions).

in the human populations. The steps to achieve this goal are as follows:

serological testing of rural poultry or sentinel chickens groups.

order to detect WNV-specific IgM early antibodies (recent infection).

Epidemiological surveillance of human cases.

The main objectives of human surveillance are the following:


The human surveillance is carried out throughout the year. However, during the period of a major vector activity (June–October), the surveillance system will have to be strengthened (in terms of timeliness and sensitivity) in mosquito-infested areas, to allow the identification of cases, for the immediate adoption of the necessary control measures (in relation to entomological surveillance) and to reduce the risk of transmission.

Therefore, from the beginning of June to the end of October, particular attention must be paid to:

• adulticide treatment (1 cycle);

• follow-up for the week following the alert.

**conditions**, the following activities must be activated:

vectors;

**December–March**

**April–May and November**

for all the vector season;

• elimination of breeding sites; • adulticide treatment (1 cycle);

• follow-up for all the vector season.

**Measures for human cases**

measures on blood donation and transplant activities.

positive house;

vectors;

• no activities

**Area C**

• treatment of non-removable breeding sites with larvicidal products;

• treatment of non-removable breeding sites with larvicidal products;

• in case of outbreak, repeat the disinfestation protocol after the first week;

• information to the inhabitants about preventive measures to apply to avoid contact with

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In the presence of human cases (probable and confirmed) **regardless of the seasonal climatic** 

• activation or enhancement of entomological surveillance around the house of the patient

• treatments on private and public land, in an area within a radius of 200 m around the

• information to the inhabitants about preventive measures to apply to avoid contact with

• replication of all interventions in case of rain or poor efficacy of the first treatment cycle;

**Human cases are notified** by Regional and local authorities to the MoH and to the Istituto Superiore di Sanità (ISS, national public health institute) using a specific password-protected web-based system, which permits to report probable and confirmed cases, adding available epidemiological (including the province of exposure), clinical and laboratory information. The web-based system is accessible also to the National Blood Center (NBC) and to the National Transplant Center (NTC), which in cases of WNV human cases will implement precautionary

In order to reduce the disease spread, the home isolation of the case is recommended up to the exclusion of the disease and, in any case, not beyond the time course of viremia. The adoption of protective measures against vector bites is essential to interrupt the transmission cycle.


The plan defines, in a given area, three situations with different risk levels depending on vectors presence and density and occurrence of human cases:

Area A: the vector is present/absence of human cases; Area B: the vector is present/one or more imported human cases; Area C: the vector is present/isolated autochthonous cases/outbreaks.

For each area, the actions to carry out during the vector season and the rest of the year are defined:

#### **Area A**

#### **December–May and November**

• no activities

#### **June to October**


#### **Area B**

#### **December–March**

• no activities

#### **April–May and November**

In the presence of human cases (probable and confirmed) **depending on the seasonal climatic conditions**, the following activities must be activated:


#### **Area C**

Therefore, from the beginning of June to the end of October, particular attention must be paid

• early identification of suspected cases (symptomatic cases returning from an endemic

• identification of people with compatible clinical symptoms but who did not travel to endemic countries, to early detect autochthonous outbreaks (two or more cases occurred

The plan defines, in a given area, three situations with different risk levels depending on vec-

Area A: the vector is present/absence of human cases; Area B: the vector is present/one or more imported human cases; Area C: the vector is present/isolated autochthonous cases/outbreaks.

For each area, the actions to carry out during the vector season and the rest of the year are

• monitoring and treatment protocols, if already existing, following Regional or national

• prevention activities: health education, methods of vector control including the elimination or management of breeding sites, larviciding with insecticides, the use of biological agents

In the presence of human cases (probable and confirmed) **depending on the seasonal cli-**

• activation or enhancement of entomological surveillance around the house of the patient

• treatments on private and public land, in an area within a radius of 200 m around the

to:

Country);

defined:

**Area A**

• no activities

**June to October**

legislation;

**December–March**

positive house;

• elimination of breeding sites;

**April–May and November**

• no activities

**Area B**

within 30 days in a restricted area).

58 Current Topics in Tropical Emerging Diseases and Travel Medicine

**December–May and November**

avoiding the application of adulticides.

for at least 2 weeks from reporting;

**matic conditions**, the following activities must be activated:

tors presence and density and occurrence of human cases:

#### **December–March**

• no activities

#### **April–May and November**

In the presence of human cases (probable and confirmed) **regardless of the seasonal climatic conditions**, the following activities must be activated:


**Human cases are notified** by Regional and local authorities to the MoH and to the Istituto Superiore di Sanità (ISS, national public health institute) using a specific password-protected web-based system, which permits to report probable and confirmed cases, adding available epidemiological (including the province of exposure), clinical and laboratory information. The web-based system is accessible also to the National Blood Center (NBC) and to the National Transplant Center (NTC), which in cases of WNV human cases will implement precautionary measures on blood donation and transplant activities.

#### **Measures for human cases**

In order to reduce the disease spread, the home isolation of the case is recommended up to the exclusion of the disease and, in any case, not beyond the time course of viremia. The adoption of protective measures against vector bites is essential to interrupt the transmission cycle.

Other family members and people should use general precautions for parenterally transmitted diseases, such as:

*3.1.1. Area under surveillance: Piemonte and Liguria regions*

nate the landscape in the northeast part of the Region.

strip of land (5.416 km<sup>2</sup>

in Italy in the city of Genova in 1990.

Regions in Italy to the East.

mercial area.

The study area includes Piemonte and Liguria regions, in Northwestern Italy (**Figure 2**). Piemonte region is the second largest Italian Region by geographical area (25.402 km<sup>2</sup>

comprises eight Provinces. It is surrounded on three sides by the Alps. About 41% of the Region is mountainous (prealpine and alpine) and 59% is hilly or flat. It is crossed from the West to the East by the Po river and bounded to the East by the Ticino river. Surrounding highly urbanized areas are intensive agriculture farmlands; they cover approximately 960,000 hectares where cereals and forage are predominantly cultivated; extensive rice fields domi-

Liguria is one of Italian smallest Regions. It is divided into four Provinces. It is a narrow

Maritime Alps and Ligurian Apennines beyond the narrow strip of coast descends almost immediately to a considerable marine depth. It represents an important touristic and com-

Characteristic rocky coasts and seascape attract many travellers to spend the holidays in the most famous tourist resorts along the Italian Riviera. The Port of her capital City Genova, with a trade volume of 58.6 million tonnes, is the first port of Italy. The invasive alien tiger mosquito (*Aedes albopictus*), which is an important vector of viral MBDs, was firstly detected

Piemonte and Liguria Region neighbours on areas where WNV is historically endemic: Camargue and Var in Southeastern France [36] to the West, Lombardy and Emilia Romagna

**Figure 2.** Map of Italy with regional boundaries. Piedmont and Liguria in the upper left, in white colour.

), highly urbanized, overlooking the Mediterranean Sea: the ring of

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61


#### **Risk communication**

Risk communication, training, information and health education have a decisive role in obtaining people collaboration.

Since there are currently no vaccines and/or therapies for the prevention and treatment of diseases as Chikungunya and Dengue (authorized only in some endemic countries) and Zika, the most effective prevention is to reduce people exposure to mosquito bites.

Currently, therefore, the key message is: 'Protect yourself from mosquito bites' which includes both the active control of the vector (use of insecticides, reduction of breeding sites) and adoption of individual protection measures (clothes, mosquito nets, repellents and also preventive measures to avoid sexual transmission, e.g. for Zika virus).

Risk communication to travellers going to or returning from endemic areas is of primary importance:

