Alternative Names

West Nile virus

Highlights
Causes

Encephalitis, an inflammation of the brain, is rare but can be caused

by many different viruses. The main causes of viral encephalitis are:

Herpes viruses, among which herpes simplex virus is particulary important.

Arboviruses, which are transmitted by blood-sucking insects such as mosquitoes. In the U.S.,
mosquito-borne encephalitis infections include West Nile encephalitis, Eastern equine encephalitis,
Western equine encephalitis, St. Louis encephalitis, La Crosse encephalitis.
Symptoms

Encephalitis symptoms can appear within 2 days to 2 weeks of

exposure to the virus. Many people who are infected do not develop
any symptoms. In milder cases, symptoms may resemble the flu. In
severe cases of encephalitis, symptoms may include:

Fever

Headache

Vomiting

Lethargy and reduced consciousness

Seizures

Memory loss

Stiff neck and back

Confusion

Speech, hearing, and vision problems

Muscle weakness

Partial paralysis

Loss of consciousness

Coma

Treatment

Because encephalitis can be dangerous, it needs to be diagnosed

promptly. Patients are treated immediately, even before diagnostic
tests identify the specific virus that caused the illness. If herpes is a
possible cause, the standard treatment is the antiviral drug
acyclovir. Once the cause has been determined, other drugs may
be administered. Unfortunately, however, many types of
encephalitis, such as the ones caused by West Nile virus and other
arboviruses, do not respond to antiviral drugs.
Prevention

The best way to prevent becoming infected with a mosquito-borne

virus is to avoid being bitten by a mosquito. Use insect repellant
when you go outside, especially during the peak mosquito hours of
dusk and dawn. Remove mosquito-breeding environments from
your property.
2012 Record Year for West Nile Virus

According to the U.S. Centers for Disease Control, more cases of

West Nile virus were reported in 2012 than in any other year in
nearly a decade. A third of all cases occurred in Texas.
Researchers are studying the virus and trying to understand what
makes it so unpredictable and difficult to control. Fortunately, only a
small percentage of West Nile virus infections cause encephalitis.
Unfortunately, there is currently no treatment available.

Introduction
Encephalitis is a rare but potentially life-threatening inflammation of
the brain that can occur in people of all ages. The most common
cause of encephalitis is infection by a virus. In very rare cases,
encephalitis can also be caused by bacterial infection, parasites, or
complications from other infectious diseases. This report focuses on
viral encephalitis.

Encephalitis: Viral Infection of the Brain

Many viruses can cause encephalitis. The West Nile virus, for
example, has been responsible for well-publicized outbreaks in the

U.S. Most people exposed to encephalitis-causing viruses have no

symptoms. Others may experience a mild flu-like illness, but do not
develop full-blown encephalitis.
In severe cases, the infection can have devastating effects,
including:

Swelling of the brain (cerebral edema)

Bleeding within the brain (intercerebral hemorrhage)
Nerve damage (neuropathy)

The damage may cause long-term mental or physical problems,

depending on the specific areas of the brain affected.
Viral infection and inflammation
can affect multiple areas of the central nervous system, and is
categorized by its location:
Other Viral Infections of the Central Nervous System.

Meningitis: infection of the meninges (the membranes that surround the brain and spinal cord)
Meningoencephalitis: infection of both the brain and meninges

Encephalomyelitis: infection of the brain and spinal cord

Specific Viruses Associated with Encephalitis

Encephalitis caused by viruses in the United States generally fall
into the following groups:

Arboviruses are the primary cause of acute encephalitis (sudden-onset encephalitis caused by direct
infection). Arboviruses, short for "arthropod-borne viruses," are spread by mosquitoes and ticks. There
is no treatment for encephalitis caused by arboviruses.
Herpes viruses are the other major cause of encephalitis in the U.S. This virus family includes herpes
simplex, Epstein-Barr, cytomegalovirus, and varicella-zoster. Herpes simplex is the most common type
of herpes-associated encephalitis. It can cause severe brain damage, but can be treated with antiviral
medication..
Less common viral causes of encephalitis include enteroviruses, adenoviruses, and viruses
associated with childhood diseases such as measles, mumps, and rubella.

[For more information, see the Causes section in this report.]

Primary and Secondary Encephalitis

Encephalitis can develop shortly after an initial viral infection, or it
can develop when a virus that was lying dormant in the body
suddenly reactivates.

There are two ways that viruses can infect brain cells and cause
encephalitis:

Primary encephalitis is when the virus directly affects the brain or spinal cord. The resulting
inflammation can occur in one area (focal) or can occur throughout the brain (diffuse).
Secondary encephalitis, also called post-infectious encephalitis, is when the virus first attacks another
part of the body and the infection then spreads to the brain.

Causes
Herpes Viruses
The herpes virus family includes at least 8 distinct viruses that
cause infections in humans. These viruses and infections include
varicella-zoster virus (the cause of chickenpox and shingles),
Epstein-Barr virus (the cause of mononucleosis), cytomegalovirus,
and herpes virus 6. Although any herpes virus can cause
encephalitis, the herpes simplex virus is the most important cause
of encephalitis.
Herpes simplex virus (HSV) is responsible for 5 10% of
encephalitis cases worldwide. Herpes simplex encephalitis (HSE)
tends to be most severe when it affects children and older people.
There are two distinct types of the herpes simplex virus:

Herpes simplex virus 1 (HSV-1) causes most cases of adult herpes encephalitis. HSV-1 is the main
cause of oral herpes infections but it can also cause genital herpes.

Herpes simplex virus 2 (HSV-2) causes most cases of encephalitis in newborn infants. HSV-2 is the
main cause of genital herpes.

Unlike arbovirus encephalitis, herpes simplex encephalitis is

treatable, but treatment (typically intravenous acyclovir) must be
administered within the first few days of symptom onset. If left
untreated, herpes simplex encephalitis can be fatal. [For more
information, seeIn-Depth Report #52: Herpes simplex.]

Arboviruses
Arboviruses, including the West Nile virus, are transmitted by bloodsucking insects such as mosquitoes and ticks. Most of the time,

these viral infections initially develop in birds, which function as

the reservoir of infection. Insects that feed on the infected blood from a
diseased bird pick up the virus, and transmit it when they bite a
susceptible host (such as an animal or a human). The insects that
play a role in this disease-transmission process are referred to
as vectors.
Arboviruses multiply in blood-sucking vectors. In fact, the word
arbovirus is an acronym forarthropod-borne virus. Mosquitoes, ticks,
and many other insects are classified as arthropods. Mosquitoes
are the most common vector for arboviruses.
In general, the virus first passes through an insect before infecting a
person. These infections are not transmitted through casual contact
from one person (or animal) to another. (However, a small number
of West Nile virus cases have occurred through blood transfusions,
organ transplantation, and possibly breastfeeding.) Only a small
percentage of people who are infected by an arbovirus develop
encephalitis.
Arboviruses that cause encephalitis are primarily found in three
virus families: Togaviridae,Bunyaviridae, and Flaviviridae.
In the United States, the main mosquito-borne encephalitis strains
are Eastern equine, Western equine, St. Louis, La Crosse, and
West Nile. Equine encephalitis causes disease in both humans and,
as its name implies, horses. Powassan encephalitis is a less
common tick-borne flavivirus that occurs primarily in the northern
United States.
Japanese encephalitis, which is also transmitted by mosquito, is the
most common form of viral encephalitis to occur outside of the
United States. It is endemic in rural areas in east, south, and
southwest Asia, especially China and Korea. Venezuelan equine
encephalitis is found in South and Central America.
Different arboviruses cause different forms of encephalitis. Although
the overall disease is the same, there are subtle differences in
symptoms and the type of brain damage they produce.

Common Forms of Mosquito-Borne Arbovirus

Encephalitis
Eastern Equine Encephalitis
Virus Family

Togaviridae (genus Alphavirus)

U.S.
Geographic
Areas

Atlantic and Gulf coasts, in New England, and around the Great Lakes. States
most affected are Florida, Georgia, Massachusetts, and New Jersey.

Symptom
Onset

Symptoms appear 4 - 10 days following infection and can range from mild flulike symptoms to full-blown encephalitis.

Incidence and
Mortality
Rates

About 6 cases are reported each year. About a third of people who contract
EEE die from it. Children are more likely to survive but also to suffer
complications afterward.

Age Risk
Groups

Adults over age 50 and children under age 15.

Western Equine Encephalitis

Virus Family

Togaviridae (genus Alphavirus)

U.S.
Geographic
Areas

Farming areas in western and central Plains and Rocky Mountain states west of
the Mississippi.

Symptom
Onset

5 - 10 days following infection.

Incidence and
Mortality
Rates

Very rare. Mortality rate is 3 - 4%; 30% of survivors have complications

afterward. Most severe in children, especially those younger than 1 year.
Infants may suffer permanent neurological damage.

Age Risk
Groups

Infants younger than 12 months.

St. Louis Encephalitis

Virus Family

Flaviviridae (genus Flavivirus)

U.S.
Geographic
Areas

Takes its name from an epidemic in St. Louis, but has occurred throughout the
U.S., especially central and southern states, as well as parts of Canada,
Caribbean, and South America.

Symptom
Onset

5 - 15 days following infection.

Incidence and
Mortality
Rates

Mortality rate range between 5 - 30%, with highest rates among elderly. About
5% of survivors suffer complications afterward.

Age Risk

Elderly adults (over age 60) are at highest risk, and the disease is most severe

Groups

in this age group. Younger people usually experience mild, flu-like symptoms.

La Crosse Encephalitis
Virus Family

Bunyaviridae (genus Bunyavirus)

U.S.
Geographic
Areas

Occurs most frequently in upper Midwestern, southeastern (Appalachia), and

mid-Atlantic states. Most cases have occurred in Ohio and Wisconsin. Unlike
other encephalitis viruses which originate in birds, La Crosse encephalitis is
transmitted to mosquitoes from infected chipmunks and squirrels.

Symptom
Onset

5 - 15 days following infection.

Incidence and
Mortality
Rates

Mortality rates are less than 1%. More common and severe in children under
age 16.

Age Risk
Groups

Children younger than 16 years.

West Nile Encephalitis

Virus Family

Flaviviridae (genus Flavivirus).

U.S.
Geographic
Areas

Cases have been reported throughout the mainland United States.

Symptom
Onset

3 - 14 days following infection.

Incidence and
Mortality
Rates

In 2012, 5,387 cases of WNV were reported to the CDC, with 243 deaths. Of
all the reported cases, 49% took the form of West Nile fever, while 51% were
meningitis and encephalitis. However, most cases of West Nile virus do not
produce symptoms, and are not reported, so these numbers imply a more
worrisome picture than actually exists. In fact, fewer than 1% of people who
are infected with WNV go on to develop neurological disease.

Age Risk
Groups

Adults over age 50.

Until 1999, the West Nile virus was generally

restricted to Africa, the Middle East, southwestern Asia, eastern
Europe, and Australia. It emerged in the United States with the first
outbreak in New York City in 1999. WNV is now found in birds and
mosquitoes in every state except Alaska and Hawaii.
Human cases of West Nile encephalitis have been reported
throughout the continental United States. In 2012, Texas had by far
the greatest number of reported cases of WNV (1739 cases)
followed by California (451), Louisiana (335), and Illinois (282).
West Nile Virus (WNV).

Throughout the United States, 2012 was a record year for West Nile
virus, with the largest number of cases in nearly a decade.
WNV, discovered in Uganda in 1937, circulates
primarily between birds and mosquitoes and can be carried long
distances by migrating birds. In a given geographic area, the
appearance of the virus among birds and mosquitoes generally
precedes infection in humans. WNV has infected over 110 species
of birds. In addition to mosquito-to-human transmission, other
causes of human infection have included blood transfusions and
organ transplantation. The U.S. now uses screening tests to detect
West Nile virus in donated blood and organs. There have also been
cases of mother-to-child transmission during pregnancy, and one
confirmed case of transmission through breastfeeding.
Severity of WNV. About 80% of people infected with WNV will not develop
symptoms. Twenty percent will develop West Nile fever (which
includes fever, headache, and occasional skin rash). Less than 1%
of infected people will develop neuroinvasive disease, the most
severe form of WNV. It is still not clear if the physical and mental
symptoms of West Nile virus persist long term.
Neuroinvasive disease affects the nervous system and includes
encephalitis, meningitis, and spinal cord infection. People over age
50 and those with weakened immune systems are at the greatest
risk for neuroinvasive disease. In older adults, neuroinvasive
disease usually manifests as encephalitis. In children and younger
adults, meningitis is more common. The fatality rate for those
afflicted ranges from 3 - 15%. Neuroinvasive disease symptoms
include high fever, headache, stiff neck, stupor, disorientation,
coma, tremors, convulsions, muscle weakness, and paralysis.
There are currently no vaccines to prevent WNV or specific antiviral
drugs to treat it.
How WNV Is Transmitted.

Tick-Borne Encephalitis Viruses

Tick-borne encephalitis (TBE) is commonly found in many countries
throughout Europe, Asia, and the former Soviet Union, but it is
reported only rarely in the U.S. Powassan encephalitis is the main

tick-borne encephalitis found in the United States and Canada. The

first human encephalitis fatality caused by deer tick virus, which is
closely related to Powasson virus, was reported in 2009. Cases of
tick-borne encephalitis have also been reported from Rocky
Mountain spotted fever, but this is a bacterial (not viral) infection.

Other Viral Causes of Encephalitis

The rabies virus is transmitted from the saliva of an infected
animal. The encephalitis it causes is virtually always fatal but is very
rare in the U.S. Only one or two cases are typically reported each
year, usually from contact with raccoons, bats, or other wild
animals.
Encephalitis Associated with Childhood Diseases. Vaccines have virtually eliminated
encephalitis caused by common childhood infections such as
measles, mumps, rubella, and chickenpox. Encephalitis can still
occur in rare cases, particularly with immunocompromised children.
Adenoviruses.Adenoviruses typically cause respiratory or eye infections,
but in rare cases they can cause encephalitis.
Enteroviruses. Enteroviruses include various viruses that enter the body
through the gastrointestinal tract. They account for about 5% of viral
encephalitis cases, usually caused by types of coxsackievirus.
Rabies.

Parasitic Causes of Encephalitis

Toxoplasmosis is a parasitic disease that can be
transmitted through a cat's feces or by eating contaminated food.
The condition causes mild symptoms in most people but
toxoplasmosis can occasionally cause encephalitis. Adults with
weakened immune systems (such as people with HIV/AIDS) are at
highest risk for developing toxoplasmosis encephalitis. In addition,
in pregnant women toxoplasmosis can cause severe problems in
the fetus central nervous system and eyes. .
Raccoon Roundworm. Raccoon roundworm (Baylisascaris procyonis) lives in the
intestines of raccoons. Humans usually become infected by
ingesting the worm's eggs through accidental contact with soil,
wood chips, or tree bark contaminated with raccoon feces. The
Toxoplasmosis.

worm is harmless in raccoons but can produce severe central

nervous system disease, including encephalitis, in people.
(Raccoons should not be kept as pets.) .
Other Parasitic Infections. Encephalitis may be caused by other parasitic
infections such as toxocariasis (from roundworms found in dogs and
cats) or cysticercosi (from food or water contaminated with pork
tapeworm eggs). People with weakened immune systems are at
highest risk for these forms of encephalitis.

Bacterial and Fungal Organisms

In very rare circumstances, encephalitis may be caused by bacterial
or fungal organisms.

Risk Factors
Encephalitis is a relatively rare disease. People at highest risk for
encephalitis, and its complications, include the very young, the very
old, and people with weakened immune systems..

Age
Encephalitis can occur at any age. Age-associated risks depend on
the type of encephalitis virus. Newborn infants are particularly at risk
for herpes simplex encephalitis. For arboviruses, infants are most
vulnerable to Western equine encephalitis. Older children and
teenagers are more susceptible to Eastern equine and La Crosse
encephalitis. Older and elderly adults are at higher risk for Eastern
equine, St. Louis, and West Nile encephalitis.

Weakened Immune System and Other Medical

Conditions
Patients whose immune systems are compromised by conditions
such as HIV-AIDS, cancer therapies, or organ transplantation are
more susceptible than other individuals to any form of encephalitis.

Other medical conditions that may increase the risk for viral
encephalitis include chronic kidney disease, diabetes, and alcohol
abuse and dependence.

Risk Factors for Herpes Simplex Encephalitis

Herpes simplex encephalitis (HSE) can be caused by either:

A new infection through person-to-person contact or

Reactivation of a latent pre-existing herpes infection.

The herpes simplex virus is very common and most people have
been infected with at least one of its two types:

Most cases of herpes simplex encephalitis occur in adults and are caused by herpes simplex virus 1
(HSV-1), which is transmitted through skin or oral contact. Half of all adults who contract HSE are
older than age 50.

Encephalitis caused by herpes simplex 2 virus (HSV-2) usually occurs in newborn infants and is
transmitted from an infected mother during delivery. HSV-2 is usually spread through sexual contact. .

[For more information, see In-Depth Report #52: Herpes simplex .]

Risk Factors for Arboviruses

The primary risk factor for arbovirus encephalitis is living in
areas of possible exposure to virus-carrying mosquitoes. Most
arbovirus outbreaks occur in rural or farming areas, but they can
also occur in cities. While some forms of arbovirus are limited to
specific geographical regions, the West Nile virus has become
endemic throughout the mainland United States. However,
encephalitis only occurs in a small percentage of West Nile
infections. [See Common Forms of Mosquito-Borne Encephalitis table for more
detailed regional information.]
Season. Transmission of arboviruses correlates with the mosquito
season and is highest during the months of July through September
(late summer through early fall). The ideal conditions for mosquito
breeding are a wet spring followed by a hot, dry summer.
Geography.

Prognosis

Mild Encephalitis
Mild cases of encephalitis can resemble the flu. Most people who
have mild cases of encephalitis make a full recovery within 2 4
weeks.

Severe Encephalitis
Prognosis for severe encephalitis depends on many factors,
including:

Age of the patient -- worse outcomes for infants under age 12 months and adults over age 55

Immune status

Preexisting neurological conditions

Virulence of the virus

In very severe cases of encephalitis, the swelling of the brain inside

the skull places downward pressure on the brain stem. The brain
stem controls vital functions, such as respiration and heartbeat. If
the pressure becomes too severe, these vital functions can cease
and cause death.

Complications from Brain Damage

Survivors of encephalitis often experience neurologic
consequences, which can be long-term and even permanent. The
degree and type of brain damage can vary from mild-to-severe and
from focal (in one part of the brain) to multifocal (several parts of the
brain) todiffuse (throughout the brain).
While coma can occur in patients with severe encephalitis, it does
not necessarily predict a fatal or severe outcome. Some patients
experience no or mild-to-moderate complications after awakening
from an encephalitis-associated coma.
The location and severity of the infection largely determines the
pattern of brain damage and its effects, which can be:

Physical (muscle control)

Behavioral and emotional (personality changes)

Cognitive (memory, speech)

Sensory (vision, hearing)

Symptoms
Symptoms of encephalitis usually appear within 2 days to 2 weeks
of exposure to the virus. In milder cases, symptoms may resemble
the flu. In severe cases of full-blown encephalitis, symptoms may
include:

Behavioral and personality changes

Sensitivity to light

Fever

Headache

Vomiting

Lethargy and reduced consciousness

Memory loss

Stiff neck and back -- accompanied by fever and headache would indicate meningitis

Confusion

Speech, hearing, and vision problems

Muscle weakness

Seizures

Partial paralysis

Loss of consciousness

Coma

Patients experiencing these types of symptoms (especially if they

may have recently been bitten by a mosquito or tick or if they have
lesions on the lips or genitals) should immediately seek medical
treatment.
Infants with herpes virus encephalitis may develop
lesions in the mouth, in the eye, or on the skin 1 - 45 days after
birth. Other symptoms include lethargy, seizures, and changes in
Symptoms in Infants.

temperature. The fontanels, the soft spots on their head where the
skull has not yet closed, may bulge outward.

Diagnosis
Because the various types of encephalitis produce similar
symptoms, doctors cannot rely on clinical features to differentiate
among the many causes of brain inflammation. The primary
objective in diagnosing viral encephalitis is to determine if it is
caused by:

Herpes simplex or other conditions that can be treated with specific medications

Arboviruses or other viruses that can be managed only by targeting symptoms

Imaging Techniques
If the doctor suspects encephalitis, a scanning technique is often
the first diagnostic step. Computerized tomography (CT) or
magnetic resonance imaging (MRI) scans can show the extent of
the inflammation in the brain and help differentiate encephalitis from
other conditions. MRIs are recommended over CT scans because
they can detect injuries in parts of the brain that suggest infection
with herpes virus at the onset of the disease, while CT scans
cannot.
Electroencephalogram (EEG), which records brain waves, may
reveal abnormalities in the temporal lobe that are indicative of
herpes simplex encephalitis.

Cerebrospinal Fluid Tests

When encephalitis is suspected, a sample of cerebrospinal fluid is
taken using a lumbar puncture, which involves inserting a needle
between two vertebrae in the patient's lower back. The sample is
taken to count white blood cells and identify specific blood cell
types, to measure proteins and blood sugar levels, and to determine
spinal fluid pressure.

Doctors can use cerebrospinal fluid to test for herpes viruses, and to
look for the presence of antibodies to the West Nile virus or other
virus types. While cerebrospinal fluid tests may help diagnose
encephalitis, they cannot provide information on how severe the
disease will be.

Blood Tests
Blood tests may be used to test for West Nile virus and other
arbovirus infections.

Brain Biopsy
If necessary, tiny samples of brain tissue are surgically removed for
examination and testing for the presence of the virus. Tissue is
prepared using staining techniques and then viewed under an
electron microscope. In a few cases, the viruses in brain cells are
able to be cultured; that is, the viruses can actually be made to
replicate in samples. A brain biopsy is the gold standard for
diagnosing rabies.

Treatment
With the exception of herpes simplex and varicella-zoster
encephalitis, the viral forms of encephalitis are not treatable. The
primary objective is to diagnose the patient as soon as possible so
they receive the right medicines to treat the symptoms. It is very
important to lower fever and ease the pressure caused by swelling
of the brain.
Patients with very severe encephalitis are at risk for body-wide
(systemic) complications including shock, low oxygen, low blood
pressure, and low sodium levels. Any potentially life-threatening
complication should be addressed immediately with the appropriate
treatments.

Antiviral Drug Treatment

Although it is difficult to quickly determine the cause of encephalitis,

rapid treatment is essential. Clinical guidelines recommend
immediately administering intravenously the antiviral drug acyclovir
without waiting to determine the cause of the illness. Ganciclovir is
another antiviral drug that is used to treat some types of herpes
encephalitis.

Additional Treatments
Other encephalitis treatments are aimed at reducing symptoms.

Seizures may be prevented by using oral anticonvulsant drugs or intravenous lorazepam (Ativan).

Corticosteroids may be given to reduce brain swelling.

Sedatives may be prescribed for irritability or restlessness.

Mild cases of encephalitis can be treated with simple pain relievers (ibuprofen, acetaminophen) for
fever and headache, fluids, and bed rest.

Investigational Treatments
No specific drugs have been effective for treating arboviruses,
including West Nile virus, although a number of drugs used to treat
other virus infections are being investigated. They include interferon
alfa 2a (Roferon-A) and other interferons.

Vaccinations
Certain vaccinations can help prevent the diseases that can lead to
encephalitis.

Measles
Measles used to be a very common childhood disease. In about 1 in
1,000 patients it can lead to encephalitis or death. The risk for these
severe complications is highest in the very young and very old.
Aggressive vaccination programs have reduced the incidence of
measles in the U.S. to fewer than 100 cases a year. Rarely, patients
who receive the live-measles vaccine develop encephalopathy

(brain damage), but the risk is far lower than brain problems
occurring from the disease itself.

Vaccine for Varicella Virus (Chickenpox and

Shingles)
Herpes zoster, or shingles, is a reactivation of the varicella virus,
which causes chickenpox. Children (and adults who do not have a
history of infection and who lack evidence of immunity) should
receive 2 doses of the chickenpox vaccine. A vaccine for shingles
(Zostavax) is available for adults age 50 years and older. [For more
information, see In-Depth Report #82: Shingles and Chickenpox.]

Vaccines for Arboviruses

A vaccine (Ixiaro) is currently available for adults traveling for a
month or longer to Asian regions where Japanese encephalitis is
endemic. (An older vaccine, JE-VAX, is no longer manufactured, but
limited quantities are available for vaccinating children.) Countries
and regions with high rates of Japanese encephalitis include Viet
Nam, Cambodia, Myanmar (Burma), southern India, Pakistan,
Nepal, Malaysia, Korea, northern Thailand, Malaysia, Sri Lanka,
and the Philippines.
Another type of vaccine (FSME-IMMUN) is used to prevent tickborne encephalitis (TBE) in travelers visiting regions where this type
of encephalitis is prevalent. TBE is found mainly in Eastern and
Central Europe. This vaccine is available in Canada and many
European countries, but it is not yet approved in the United States.
Several types of vaccines are under investigation for West Nile
virus, but it will be several years before these vaccines could
become commercially available.

Rabies Vaccine and Immune Globulin

Anyone exposed to the secretions of an animal suspected of having
rabies, should be evaluated for post-exposure rabies vaccine.

Exposed individuals may also receive immune globulin unless they

were previously vaccinated. The regimen is one shot of immune
globulin and four shots of rabies vaccine given over a period of two
weeks. The new types of rabies vaccines cause much less
discomfort and many fewer adverse effects than the older ones.
Side effects may include mild reactions such as pain, redness, or
swelling at the injection site. Patients may experience pain at the
injection site and low-grade fever following the immune globulin
shot.

Prevention
The risk for mosquito-borne infections is highest between dusk and
dawn, when mosquitoes feed. A good insect repellent is very helpful
in reducing the risk for vector-borne disease. The most complete
personal protection program for adults and most children is to apply
the insect repellant DEET to the skin, and also permethrin to
clothing and similar surfaces.

DEET and Other Insect Repellant Skin Products

Most insect repellents contain the chemical DEET (N,N-diethylmeta-toluamide), which remains the gold standard of currently
available mosquito and tick repellents. DEET has been used for
more than 40 years and is safe for most children when used as
directed. Comparison studies suggest that DEET preparations are
the most effective insect repellents now available.
Concentrations range from 4% to almost 100%. The concentration
determines the duration of protection. Most adults and children over
12 years old should use preparations containing a DEET
concentration of 20 - 35% (such as Ultrathon), which provides
complete protection for an average of 5 hours. (Higher DEET
concentrations may be necessary for adults who are in high-risk
regions for prolonged periods.)
DEET.

DEET products should never be used on infants younger than 2

months. According to the Environmental Protection Agency (EPA),

DEET products can safely be used on all children age 2 months and
older. The EPA recommends that parents check insect repellant
product labels for age restrictions. If there is no age restriction
listed, the product is safe for any age. The American Academy of
Pediatrics recommends that children use concentrations of 10% or
less; 30% DEET is the maximum concentration that should be used
for children. When deciding what concentration is most appropriate,
parents should consider the amount of time that children will be
spending outside, and the risk of mosquito bites and mosquitoborne disease.
When applying DEET, take the following precautions:

Do not use on the face, and apply only enough to cover exposed skin on other areas.

Do not over apply, and do not use under clothing.

Do not apply over any cuts, wounds, or irritated skin.

Only parents or an adult should apply repellent to a child. They should first put DEET on their own
hands and then apply it to the child. They should avoid putting DEET not only near the child's eyes
and mouth but also on the hands (since children frequently touch their faces).

Wash any treated skin after going back inside.

If using a spray, apply DEET outdoors -- never indoors. Spray repellents should not be applied directly
on anyone's face.

The U.S. Centers for Disease Control (CDC)

also recommends the mosquito repellents picaridin and oil of lemon
eucalyptus.
Picaridin, also known as KBR 3023 or Bayrepel, is an ingredient
that has been used for many years in repellents sold in Europe,
Latin America, and Asia. A product containing 7% picaridin is now
available in the United States. Picaridin can safely be applied to
young children and is also safe for women who are pregnant or
breastfeeding. According to the CDC, insect repellents containing
DEET or picaridin work better than other products.
Other Insect Repellent Products.

In scientific tests, oil of lemon eucalyptus, also known as PMD,

worked as well as low concentrations of DEET. However, oil of
lemon eucalyptus is not recommended for children under the age of
3 years.

Permethrin for Clothing and Surfaces

Permethrin is an insect repellent used as a spray for clothing and
bed nets, which can repel insects for weeks when applied correctly.
Electric vaporizing mats containing permethrin may be very helpful.
A permethrin solution is also available for soaking items, but it
should never be applied to the skin. Side effects from direct
exposure may include mild burning, stinging, itching, and rash. In
general, however, permethrin is very safe and its use may even
reduce child mortality rates from malaria. People allergic to
chrysanthemum flowers or who are allergic to head-lice scabicides
should avoid using permethrin.

Controlling Mosquitoes around the House

The best way for homeowners to reduce
mosquito populations is to eliminate sources of standing water.
Eliminate Sources of Standing Water.

Look for any source of standing water, where mosquitoes can breed. For example, discard any
rubbish with standing water, such as old tires, cans, and bottles. (Even bottle caps can breed
mosquitoes.) Do not let water accumulate in outdoor flower pot basins or pet bowls. Turn over wading
pools and wheelbarrows when not in use. Change bird bath water every 3 - 4 days. A product such as
Mosquito Dunk can be used to prevent breeding in standing water.

Swimming pools and hot tubs should be clean and chlorinated or drained and covered if not in use.

Clean vegetation and debris from the edges of ponds.

Keep gutters clean and unclogged.

Mosquito traps use various methods for

repelling or attracting and trapping female mosquitoes, which are
the primary transmitters of arboviruses. These methods include
electricity or propane. However, there is little evidence to support
their effectiveness.
Insect light traps (commonly called bug zappers), which attract and
electrocute insects, may actually spread viruses and bacteria that
are on the insects. They are also not very effective for killing female
mosquitoes.
Mosquito Traps and Bug Zappers.

Citronella Candles.

Burning citronella candles reduces the likelihood of

bites. (Indeed, burning any candle helps to some extent, perhaps

because the generation of carbon dioxide diverts mosquitoes

toward the flame.)

Other Preventive Measures

Your home environment, personal hygiene, and what you wear can
also help reduce your risk for mosquito bites:

Wear trousers and long-sleeved shirts, particularly at dusk.

Sleep only in screened areas.

Air-conditioning may reduce mosquito infiltration. Where air-conditioning is not available, fans may be
helpful. Mosquitoes appear to be reluctant to fly in windy air.

Don't wear perfumes.

Cover up bare skin after dusk.

Wash your hair at least twice a week.

Community Mosquito Control Programs

Public health measures are the most effective methods for
controlling mosquitoes. Local communities that experience
outbreaks of encephalitis or West Nile virus from mosquitoes often
have public spraying programs that target mosquito larvae during
breeding season as well as adult mosquitoes. The U.S.
Environmental Protection Agency (EPA) approves the safety of the
insecticides used. While these pesticides are generally considered
safe for humans, people with asthma or other respiratory problems
should avoid exposure by staying indoors while spraying takes
place.
Report Dead Birds. Dead birds may be indicators that the West Nile virus
has reached a specific region. Report any dead birds to your local
public health authorities. You should never touch a dead bird with
your bare hands.
Spraying.