An outbreak of West Nile Virus infection in the region of Monastir, Tunisia, 2003

Background: A West Nile (WN) fever epidemic occurred in the region of Monastir, Tunisia, between August and October 2003. Aim of the study: We attempt to describe the epidemiology, clinical presentation, and outcome of patients with confirmed West Nile virus (WNV) infection. Methods: Three groups of specimens were prepared. One was made up of serum only (n = 43), the other of cerebrospinal fluid (CSF) only (n = 30), and the third group was made up of both (n = 40). These specimens were obtained from 113 patients. A serological diagnosis and evidence of WNV genome by nested reverse-transcriptase polymerase chain reaction (nRT-PCR) and TaqMan reverse transcription-polymerase chain reaction (nRT-PCR) were carried out. Results: Thirty-eight cases (33.6%) were serologically positive. Results of nRT-PCR showed a total of 10 positive cases of WNV (8.8%) detected in group 1 (n = 1/43), group 2 (n = 5/30), and group 3 (n = 4/40) whereas the PCR TaqMan showed 18 positive samples (15.9%) found in group 1(n = 3/43), group 2 (n = 9/30), and group 3 (n = 6/40). All TaqMan PCR positive cases were nRT-PCR positive. In addition, four serologically probable cases were confirmed by TaqMan PCR. The attempts to isolate WNV by cell culture were unsuccessful. Considering the results of TaqMan assay and the serological diagnosis, WNV infection was confirmed in a total of 42 patients. The main clinical presentations were meningoencephalitis (40%), febrile disease (95%), and meningitis (36%). Eight patients (19%) died. The highest case-fatality rates occurred among patients aged >= 55 years. The phylogenetic analysis revealed that isolates of WNV were closely related to the Tunisian strain 1997 (PAH001) and the Israeli one (Is-98). Conclusions: West Nile virus is a reemerging global pathogen that remains an important public health challenge in the next decade.