Elimination of Aedes aegypti in northern Australia, 2004-2006.

The Northern Territory (NT) of Australia is currently free of the dengue mosquito Aedes (Stegomyia) aegypti (L). However, on 17 February 2004, two Ae. aegypti adults were captured in two routine CO2 -baited encephalitis virus surveillance traps in Tennant Creek, located 990 km south of Darwin in the NT. The detection triggered an immediate survey and control response undertaken by the NT Department of Health and Community Services, followed by a Commonwealth of Australia-funded Ae. aegypti elimination program. This report details the methods and results of the detection and subsequent elimination activities that were carried out between 2004 and 2006, returning the NT to its dengue vector-free status. There have been very few successful Ae. aegypti elimination programs in the world. This purposeful mosquito elimination for Australia was officially declared on 5 April 2006.

The Removal of Subterranean Stormwater Drain Sumps as Mosquito Breeding Sites in Darwin, Australia.

The Northern Territory Top End Health Service, Medical Entomology Section and the City of Darwin council carry out a joint Mosquito Engineering Program targeting the rectification of mosquito breeding sites in the City of Darwin, Northern Territory, Australia. In 2005, an investigation into potential subterranean stormwater breeding sites in the City of Darwin commenced, specifically targeting roadside stormwater side entry pits. There were 79 side entry pits randomly investigated for mosquito breeding in the Darwin suburbs of Nightcliff and Rapid Creek, with 69.6% of the pits containing water holding sumps, and 45.6% of those water holding sumps breeding endemic mosquitoes. Culex quinquefasciatus was the most common mosquito collected, accounting for 73% of all mosquito identifications, with the potential vector mosquito Aedes notoscriptus also recovered from a small number of sumps. The sumps were also considered potential dry season maintenance breeding sites for important exotic Aedes mosquitoes such as Aedes aegypti and Aedes albopictus, which are potential vectors of dengue, chickungunya and Zika virus. Overall, 1229 side entry pits were inspected in ten Darwin suburbs from 2005 to 2008, with 180 water holding sumps identified and rectified by concrete filling.

Mosquito Control and Coastal Development: How they Have Coexisted and Matured in Florida and Australia.

The aims of this review were to compare planning for both mosquito control and land use in east-central Florida, USA, and in New South Wales, Queensland, and the Northern Territory, Australia. Saltwater mosquito production in mangroves and salt marsh is the predominant mosquito control concern in all the areas. Urban encroachment towards saltwater mosquito habitats is a problem in both Florida and Australia. In east-central Florida and the Northern Territory, mosquito control is supported by comprehensive source reduction programs, whereas in Queensland and New South Wales, larviciding is the main method of control. The long-term control by source reduction programs reduces vulnerability to mosquito issues as population encroaches towards wetlands, whereas larviciding programs have to respond repeatedly as problems arise. Problems from urban encroachment are exacerbated if mosquito control and land-use planning are not integrated. Further, urban planning that is not informed by mosquito management can lead to increased mosquito problems by inadvertent design or allowing residential development close to mosquito habitats. This increases the need for mosquito control and related resourcing. At the regional level of governance, Florida and the Northern Territory generally have greater integration between planning for development and mosquito control than at the local government level in New South Wales and Queensland, where there is a lack of integration between mosquito agencies and planners. It is concluded that coordination of planning and mosquito control is more effective at higher government levels than at local levels, which have less connectivity between management areas and/or insufficient resources. The lesson is that collaboration can assist in avoiding or resolving conflicts.

Holding back the tiger: Successful control program protects Australia from Aedes albopictus expansion.

BACKGROUND: The Asian tiger mosquito, Aedes albopictus, is an important vector of dengue, chikungunya and Zika viruses and is a highly invasive and aggressive biter. Established populations of this species were first recognised in Australia in 2005 when they were discovered on islands in the Torres Strait, between mainland Australia and Papua New Guinea. A control program was implemented with the original goal of eliminating Ae. albopictus from the Torres Strait. We describe the evolution of management strategies that provide a template for Ae. albopictus control that can be adopted elsewhere. METHODOLOGY / PRINCIPAL FINDINGS: The control strategy implemented between 2005 and 2008 targeted larval habitats using source reduction, insect-growth regulator and pyrethroid insecticide to control larvae and adults in the containers. However, the infrequency of insecticide reapplication, the continual accumulation and replacement of containers, and imminent re-introduction of mosquitoes through people's movement from elsewhere compromised the program. Consequently, in 2009 the objective of the program changed from elimination to quarantine, with the goal of preventing Ae albopictus from infesting Thursday and Horn islands, which are the transport hubs connecting the Torres Strait to mainland Australia. However, larval control strategies did not prevent the species establishing on these islands in 2010. Thereafter, an additional strategy adopted by the quarantine program in early 2011 was harborage spraying, whereby the vegetated, well shaded resting sites of adult Ae. albopictus were treated with a residual pyrethroid insecticide. Inclusion of this additional measure led to a 97% decline in Ae. albopictus numbers within two years. In addition, the frequency of container treatment was increased to five weeks between treatments, compared to an average of 8 weeks that occurred in the earlier iterations of the program. By 2015 and 2016, Ae. albopictus populations on the two islands were undetectable in 70-90% of surveys conducted. Importantly, a comprehensive surveillance network in selected strategic areas has not identified established populations of this species on the Australian mainland. CONCLUSIONS / SIGNIFICANCE: The program has successfully reduced Ae. albopictus populations on Thursday Island and Horn Island to levels where it is undetectable in up to 90% of surveys, and has largely removed the risk of mainland establishment via that route. The vector management strategies adopted in the later years of the program have been demonstrably successful and provide a practical management framework for dengue, chikungunya or Zika virus outbreaks vectored by Ae. albopictus. As of June 2016, Ae. albopictus had not established on the Australian mainland and this program has likely contributed significantly to this outcome.

Determining meteorological drivers of salt marsh mosquito peaks in tropical northern Australia.

In northern Australia the northern salt marsh mosquito Aedes vigilax is a vector of Ross River virus and is an appreciable pest. A coastal wetland adjacent to Darwin's residential suburbs offers a favorable habitat for Ae. vigilax, and despite vigilant mosquito control efforts, peaks of Ae. vigilax occur in excess of 500/trap/night some months. To improve mosquito control for disease and nuisance biting to nearby residential areas, we sought to investigate meteorological drivers associated with these Ae. vigilax peaks. We fitted a cross-sectional logistic regression model to weekly counts of female Ae. vigilax mosquitoes collected between July, 1998 and June, 2009 against variables, tide, rainfall, month, year, and larval control. Aedes vigilax peaks were associated with rainfall during the months September to November compared with January, when adjusted for larval control and tide. To maximize mosquito control efficiency, larval control should continue to be implemented after high tides and with increased emphasis on extensive larval hatches triggered by rainfall between September and November each year. This study reiterates the importance of monitoring and evaluating service delivery programs. Using statistical modelling, service providers can obtain solutions to operational problems using routinely collected data. These methods may be applicable in mosquito surveillance or control programs in other areas.

A new species of mesonivirus from the Northern Territory, Australia.

Here we describe Casuarina virus (CASV), a new virus in the family Mesoniviridae. This is the first report of a mesonivirus in Australia, which extends the geographical range of this virus family to 3 continents. The virus was isolated in 2010 from Coquillettidia xanthogaster mosquitoes during surveillance in the suburbs of Darwin, the capital of the Northern Territory. Cryo-electron microscopy of the CASV virions revealed spherical particles of 65 nm in size with large club-shaped projections of approximately 15 nm in length. The new virus was most closely related to Alphamesonivirus 1, the only currently recognized species in the family. In 2013 a further 5 putative new mesonivirus species were described: Hana, Méno, Nsé, Moumo and Dak Nong viruses. The evolutionary distance between CASV and two of its closest relatives, Cavally and Hana viruses (Jones-Taylor-Thornton distance of 0.151 and 0.224, respectively), along with its isolation from a different genus of mosquitoes captured on a separate continent indicate that CASV is a new species.

Locally advanced and metastatic prostate cancer treated with intermittent androgen monotherapy or maximal androgen blockade: results from a randomised phase 3 study by the South European Uroncological Group.

BACKGROUND: Few randomised studies have compared antiandrogen intermittent hormonal therapy (IHT) with continuous maximal androgen blockade (MAB) therapy for advanced prostate cancer (PCa). OBJECTIVE: To determine whether overall survival (OS) on IHT (cyproterone acetate; CPA) is noninferior to OS on continuous MAB. DESIGN, SETTING, AND PARTICIPANTS: This phase 3 randomised trial compared IHT and continuous MAB in patients with locally advanced or metastatic PCa. INTERVENTION: During induction, patients received CPA 200 mg/d for 2 wk and then monthly depot injections of a luteinising hormone-releasing hormone (LHRH; triptoreline 11.25 mg) analogue plus CPA 200 mg/d. Patients whose prostate-specific antigen (PSA) was <4 ng/ml after 3 mo of induction treatment were randomised to the IHT arm (stopped treatment and restarted on CPA 300 mg/d monotherapy if PSA rose to ≥20 ng/ml or they were symptomatic) or the continuous arm (CPA 200 mg/d plus monthly LHRH analogue). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome measurement was OS. Secondary outcomes included cause-specific survival, time to subjective or objective progression, and quality of life. Time off therapy in the intermittent arm was recorded. RESULTS AND LIMITATIONS: We recruited 1045 patients, of which 918 responded to induction therapy and were randomised (462 to IHT and 456 to continuous MAB). OS was similar between groups (p=0.25), and noninferiority of IHT was demonstrated (hazard ratio [HR]: 0.90; 95% confidence interval [CI], 0.76-1.07). There was a trend for an interaction between PSA and treatment (p=0.05), favouring IHT over continuous therapy in patients with PSA ≤1 ng/ml (HR: 0.79; 95% CI, 0.61-1.02). Men treated with IHT reported better sexual function. Among the 462 patients on IHT, 50% and 28% of patients were off therapy for ≥2.5 yr or >5 yr, respectively, after randomisation. The main limitation is that the length of time for the trial to mature means that other therapies are now available. A second limitation is that T3 patients may now profit from watchful waiting instead of androgen-deprivation therapy. CONCLUSIONS: Noninferiority of IHT in terms of survival and its association with better sexual activity than continuous therapy suggest that IHT should be considered for use in routine clinical practice.

Differences in time to disease progression do not predict for cancer-specific survival in patients receiving immediate or deferred androgen-deprivation therapy for prostate cancer: final results of EORTC randomized trial 30891 with 12 years of follow-up.

BACKGROUND: Trials assessing the benefit of immediate androgen-deprivation therapy (ADT) for treating prostate cancer (PCa) have often done so based on differences in detectable prostate-specific antigen (PSA) relapse or metastatic disease rates at a specific time after randomization. OBJECTIVE: Based on the long-term results of European Organization for Research and Treatment of Cancer (EORTC) trial 30891, we questioned if differences in time to progression predict for survival differences. DESIGN, SETTING, AND PARTICIPANTS: EORTC trial 30891 compared immediate ADT (n=492) with orchiectomy or luteinizing hormone-releasing hormone analog with deferred ADT (n=493) initiated upon symptomatic disease progression or life-threatening complications in randomly assigned T0-4 N0-2 M0 PCa patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Time to first objective progression (documented metastases, ureteric obstruction, not PSA rise) and time to objective castration-resistant progressive disease were compared as well as PCa mortality and overall survival. RESULTS AND LIMITATIONS: After a median of 12.8 yr, 769 of the 985 patients had died (78%), 269 of PCa (27%). For patients receiving deferred ADT, the overall treatment time was 31% of that for patients on immediate ADT. Deferred ADT was significantly worse than immediate ADT for time to first objective disease progression (p<0.0001; 10-yr progression rates 42% vs 30%). However, time to objective castration-resistant disease after deferred ADT did not differ significantly (p=0.42) from that after immediate ADT. In addition, PCa mortality did not differ significantly, except in patients with aggressive PCa resulting in death within 3-5 yr after diagnosis. Deferred ADT was inferior to immediate ADT in terms of overall survival (hazard ratio: 1.21; 95% confidence interval, 1.05-1.39; p [noninferiority]=0.72, p [difference] = 0.0085). CONCLUSIONS: This study shows that if hormonal manipulation is used at different times during the disease course, differences in time to first disease progression cannot predict differences in disease-specific survival. A deferred ADT policy may substantially reduce the time on treatment, but it is not suitable for patients with rapidly progressing disease.

Applications of a sugar-based surveillance system to track arboviruses in wild mosquito populations.

Effective arbovirus surveillance is essential to ensure the implementation of control strategies, such as mosquito suppression, vaccination, or dissemination of public warnings. Traditional strategies employed for arbovirus surveillance, such as detection of virus or virus-specific antibodies in sentinel animals, or detection of virus in hematophagous arthropods, have limitations as an early-warning system. A system was recently developed that involves collecting mosquitoes in CO2-baited traps, where the insects expectorate virus on sugar-baited nucleic acid preservation cards. The cards are then submitted for virus detection using molecular assays. We report the application of this system for detecting flaviviruses and alphaviruses in wild mosquito populations in northern Australia. This study was the first to employ nonpowered passive box traps (PBTs) that were designed to house cards baited with honey as the sugar source. Overall, 20/144 (13.9%) of PBTs from different weeks contained at least one virus-positive card. West Nile virus Kunjin subtype (WNVKUN), Ross River virus (RRV), and Barmah Forest virus (BFV) were detected, being identified in 13/20, 5/20, and 2/20 of positive PBTs, respectively. Importantly, sentinel chickens deployed to detect flavivirus activity did not seroconvert at two Northern Territory sites where four PBTs yielded WNVKUN. Sufficient WNVKUN and RRV RNA was expectorated onto some of the honey-soaked cards to provide a template for gene sequencing, enhancing the utility of the sugar-bait surveillance system for investigating the ecology, emergence, and movement of arboviruses.

Arboviral diseases and malaria in Australia, 2010-11: annual report of the National Arbovirus and Malaria Advisory Committee.

The National Notifiable Diseases Surveillance System (NNDSS) received notification of 9,291 cases of disease transmitted by mosquitoes during the 2010-11 season (1 July 2010 to 30 June 2011). The alphaviruses Barmah Forest virus and Ross River virus accounted for 7,515 (81%) of these. There were 133 notifications of dengue virus infection acquired in Australia and 1,133 cases that were acquired overseas, while for 10 cases, the place of acquisition was unknown. The number of overseas acquired cases of dengue continues to rise each year, and these are most frequently acquired in Indonesia. Sentinel chicken, mosquito surveillance, viral detection in mosquitoes and climate modelling are used to provide early warning of arboviral disease activity in Australia. In early 2011, sentinel chickens in south eastern Australia widely seroconverted to flaviviruses. In 2010-11, there were 16 confirmed human cases of Murray Valley encephalitis acquired in Australia. There was one human case of Kunjin virus infection. There were 7 notifications of locally-acquired malaria in Australia and 407 notifications of overseas-acquired malaria during the 2010-11 season.

A new insect-specific flavivirus from northern Australia suppresses replication of West Nile virus and Murray Valley encephalitis virus in co-infected mosquito cells.

Recent reports of a novel group of flaviviruses that replicate only in mosquitoes and appear to spread through insect populations via vertical transmission have emerged from around the globe. To date, there is no information on the presence or prevalence of these insect-specific flaviviruses (ISFs) in Australian mosquito species. To assess whether such viruses occur locally, we used reverse transcription-polymerase chain reaction (RT-PCR) and flavivirus universal primers that are specific to the NS5 gene to detect these viruses in mosquito pools collected from the Northern Territory. Of 94 pools of mosquitoes, 13 were RT-PCR positive, and of these, 6 flavivirus isolates were obtained by inoculation of mosquito cell culture. Sequence analysis of the NS5 gene revealed that these isolates are genetically and phylogenetically similar to ISFs reported from other parts of the world. The entire coding region of one isolate (designated 56) was sequenced and shown to have approximately 63.7% nucleotide identity and 66.6% amino acid identity with its closest known relative (Nakiwogo virus) indicating that the prototype Australian ISF represents a new species. All isolates were obtained from Coquillettidia xanthogaster mosquitoes. The new virus is tentatively named Palm Creek virus (PCV) after its place of isolation. We also demonstrated that prior infection of cultured mosquito cells with PCV suppressed subsequent replication of the medically significant West Nile and Murray Valley encephalitis viruses by 10-43 fold (1 to 1.63 log) at 48 hr post-infection, suggesting that superinfection exclusion can occur between ISFs and vertebrate-infecting flaviviruses despite their high level of genetic diversity. We also generated several monoclonal antibodies (mAbs) that are specific to the NS1 protein of PCV, and these represent the first ISF-specific mAbs reported to date.

A comparison of adult mosquito trapping regimes across seasons and ecosystems in Darwin, Australia.

Mosquitoes are problematic as vectors and pests in many tropical cities, including Darwin, the principal city in the Northern Territory of Australia. To monitor peaks in mosquito populations, the Medical Entomology unit of the Health Department sets overnight CO(2) -baited traps weekly. Trap setting and retrieving, followed by mosquito counting and identification, are labor intensive. Aiming to reduce this workload, we tested the hypothesis that fortnightly trapping is as effective as weekly trapping across seasons and ecologically distinct systems in Darwin. We applied cross-sectional negative binomial mixed effects models, which adjusted for rain and calendar month, to existing historical data. Culex annulirostris peaks were effectively identified using fortnightly trapping across all three ecological systems, during wet/dry and build-up seasonal patterns. For Aedes vigilax, fortnightly trapping was adequate in identifying peaks during wet and dry season months, but inadequate during build-up months across all three ecological systems. Therefore, weekly trapping should continue during build-up months, but trapping could be reduced to fortnightly for wet and dry season months for all ecological systems. Trapping for Cx. annulirostris monitoring could be reduced to fortnightly in all areas and seasons. Evaluation of programs can maximize staff efficiency and improve service delivery by reducing the need for unnecessary tasks.

Arboviral diseases and malaria in Australia, 2009-10: annual report of the National Arbovirus and Malaria Advisory Committee.

The National Notifiable Diseases Surveillance System received 7,609 notified cases of disease transmitted by mosquitoes for the season 1 July 2009 to 30 June 2010. The alphaviruses Barmah Forest virus and Ross River virus, accounted for 6,546 (79%) of these notifications during the 2009-10 season. There were 37 notifications of dengue virus infection locally-acquired from North Queensland and 581 notified cases in Australia that resulted from overseas travel. This number of overseas acquired cases continues to rise each year due to increasing disease activity in the Asia-Pacific region and increased air travel. Detection of flavivirus seroconversions in sentinel chicken flocks across Australia provides an early warning of increased levels of Murray Valley encephalitis virus and Kunjin virus activity. Flavivirus activity was detected in western and northern Australia in 2009-10, which prompted public health action. No human cases of Murray Valley encephalitis virus infection were notified, while there were 2 cases of Kunjin virus infection notified. There were no notifications of locally-acquired malaria in Australia and 429 notifications of overseas-acquired malaria during the 2009-10 season. This annual report presents information of diseases transmitted by mosquitoes in Australia and notified to the National Notifiable Diseases Surveillance System.

Adult mosquito trap sensitivity for detecting exotic mosquito incursions and eradication: a study using EVS traps and the Australian southern saltmarsh mosquito, Aedes camptorhynchus.

Adult mosquito traps are commonly used in biosecurity surveillance for the detection of exotic mosquito incursions or for the demonstration of elimination. However, traps are typically deployed without knowledge of how many are required for detecting differing numbers of the target species. The aim of this study was to determine the sensitivity (i.e., detection probability) provided by carbon dioxide-baited EVS traps for adult female Australian southern saltmarsh mosquitoes, Aedes camptorhynchus, a recent biosecurity problem for New Zealand. A mark-release-recapture study of three concurrently released cohorts (sized 56, 296, and 960), recaptured over four days with a matrix of 20 traps, was conducted in Australia. The detection probability for different numbers of traps and cohorts of different sizes was determined by random sampling of recapture data. Detection probability ranged from approximately 0.3 for a single trap detecting a cohort of 56 mosquitoes to 1.0 (certainty of detection) when seven or more traps were used. For detection of adult Ae. camptorhynchus around a known source, a matrix of traps provides a strong probability of detection. Conversely, the use of single traps deployed over very large areas to detect mosquitoes of unknown entry pathway is unlikely to be successful. These findings have implications for the design of mosquito surveillance for biosecurity.

Anthropogenic ecological change and impacts on mosquito breeding and control strategies in salt-marshes, Northern Territory, Australia.

Darwin, in the tropical north of Australia, is subject to high numbers of mosquitoes and several mosquito-borne diseases. Many of Darwin's residential areas were built in close proximity to tidally influenced swamps, where long-term storm-water run-off from nearby residences into these swamps has led to anthropogenic induced ecological change. When natural wet-dry cycles were disrupted, bare mud-flats and mangroves were transformed into perennial fresh to brackish-water reed swamps. Reed swamps provided year-round breeding habitat for many mosquito species, such that mosquito abundance was less predictable and seasonally dependent, but constant and often occurring in plague proportions. Drainage channels were constructed throughout the wetlands to reduce pooled water during dry-season months. This study assesses the impact of drainage interventions on vegetation and mosquito ecology in three salt-marshes in the Darwin area. Findings revealed a universal decline in dry-season mosquito abundance in each wetland system. However, some mosquito species increased in abundance during wet-season months. Due to the high expense and potentially detrimental environmental impacts of ecosystem and non-target species disturbance, large-scale modifications such as these are sparingly undertaken. However, our results indicate that some large scale environmental modification can assist the process of wetland restoration, as appears to be the case for these salt marsh systems. Drainage in all three systems has been restored to closer to their original salt-marsh ecosystems, while reducing mosquito abundances, thereby potentially lowering the risk of vector-borne disease transmission and mosquito pest biting problems.

Experimental comparison of aerial larvicides and habitat modification for controlling disease-carrying Aedes vigilax mosquitoes.

BACKGROUND: Microbial and insect-growth-regulator larvicides dominate current vector control programmes because they reduce larval abundance and are relatively environmentally benign. However, their short persistence makes them expensive, and environmental manipulation of larval habitat might be an alternative control measure. Aedes vigilax is a major vector species in northern Australia. A field experiment was implemented in Darwin, Australia, to test the hypotheses that (1) aerial microbial larvicide application effectively decreases Ae. vigilax larval presence, and therefore adult emergence, and (2) environmental manipulation is an effective alternative control measure. Generalised linear and mixed-effects modelling and information-theoretic comparisons were used to test these hypotheses. RESULTS: It is shown that the current aerial larvicide application campaign is effective at suppressing the emergence of Ae. vigilax, whereas vegetation removal is not as effective in this context. In addition, the results indicate that current larval sampling procedures are inadequate for quantifying larval abundance or adult emergence. CONCLUSIONS: This field-based comparison has shown that the existing larviciding campaign is more effective than a simple environmental management strategy for mosquito control. It has also identified an important knowledge gap in the use of larval sampling to evaluate the effectiveness of vector control strategies.

Habitat modification for mosquito control in the Ilparpa Swamp, Northern Territory, Australia.

Habitat modification is an established method of effective long-term mosquito management, particularly in salt-marsh environments. It is especially pertinent when mosquitoes are known vectors of life-threatening disease and their larval breeding habitat is in close proximity to residential areas. The Ilparpa Swamp is located less than 10 km from Alice Springs, Northern Territory. Wet season rainfall, often followed by effluent discharges to the swamp from the adjacent sewage treatment plant, create ideal sites for the immature stages of the common banded mosquito Culex annulirostris (Skuse), a major vector of Murray Valley encephalitis (MVEV) and Kunjin (KUNV) viruses. Subsequent to increases in notifications of MVEV disease cases in 2000 and 2001, a drainage system was established in the Ilparpa Swamp in early 2002. This paper evaluates the drainage intervention effects. Results indicate a significant reduction in mosquito numbers following habitat modification, which remain low. There have been no seroconversions in sentinel chickens to MVEV or KUNV and no human infections from these viruses in the Alice Springs urban region since the drains were completed. Habitat modification has successfully reduced mosquito numbers and minimized the risk for mosquito-borne disease to residents in Alice Springs urban and surrounding areas, which has never before been documented in Australia.

West nile virus (Kunjin subtype) disease in the northern territory of Australia--a case of encephalitis and review of all reported cases.

West Nile virus Kunjin subtype (WNV/KUNV) is enzootic across the tropical north of Australia, with epizootic spread into other jurisdictions. The clinical spectrum of illness in humans is poorly described. We report a clinical case of WNV/KUNV encephalitis and performed a retrospective chart audit of all cases of WNV/KUNV notified in the Northern Territory from 1992 to 2010. Thirteen cases of WNV/KUNV disease were identified; case notes were available for 10 of these presentations. Six of these patients had confirmed infection and presented with neuroinvasive illness, whereas the other four suspect cases comprised three cases with arthralgia, myalgia, and/or rash and one case with fever alone. On the available evidence, WNV/KUNV is of lower virulence compared with the New York 1999 strain. Difficulties in serological diagnosis, especially when paired acute and convalescent sera are not available, may adversely impact the accuracy of the epidemiological and clinical understanding of this virus.