Opinion
VIEWPOINT
Lola V. Stamm, PhD Program in Infectious Diseases, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill.
Corresponding Author: Lola V. Stamm, PhD, Department of Epidemiology, University of North Carolina at Chapel Hill, 3103 Hooker Research Center, S Columbia St, Chapel Hill, NC 27599-7435 (lstamm@email .unc.edu). jamadermatology.com
Chikungunya Emerging Threat to the United States Until recently, most Americans had never heard of chikungunya, a mosquito-transmitted disease caused by the chikungunya virus (CHIKV). This has changed as a result of an explosive outbreak of chikungunya throughout the Caribbean that has affected more than 580 000 people since December 2013.1 Although cases of chikungunya have been reported this year in the United States (eg, North Carolina, Florida, Indiana, Nebraska, Tennessee), these have virtually all been in travelers returning from the Caribbean or from chikungunyaendemic areas of Africa or Asia. 1 However, various data suggest that it is only a matter of time until CHIKV transmission is autochthonous in the continental United States and chikungunya becomes a public health problem.2-4 The likelihood of this scenario is heightened because of the presence of (1) CHIKV replication-competent mosquito vectors (ie, Aedes albopictus and Aedes aegypti); (2) a temperate climate, particularly in the southeastern United States, that is conducive to the establishment of endemic foci of chikungunya; (3) a highly susceptible population with no preexisting immunity to the virus; and (4) a large influx of viremic travelers returning from the Caribbean, coupled with the seasonal synchronicity of vector activity. The CHIKV was first isolated in Africa in the early 1950s during an outbreak in southern Tanzania.5,6 Two genetically distinct lineages of the virus have been identified, the west African lineage and the east, central, and south African lineage. The latter lineage includes the Asian genotype that is currently circulating in the Caribbean and is transferred between humans and mosquitoes without the need for animal reservoirs. Before 2000, large outbreaks of chikungunya were relatively rare. However, since 2000, large outbreaks have occurred in Africa and Asia. An outbreak in East Africa in 2004 spread to several islands in the Indian Ocean including Réunion, where in 2005 approximately 35% of the population became ill in only a few months and fatalities were reported. Since then, chikungunya outbreaks in India, Sri Lanka, and Indonesia have sickened millions. In 2007 and 2010, autochthonous transmission of CHIKV was reported for the first time in northern Italy and in southern France, respectively, as a result of the introduction of CHIKV by viremic travelers returning to Europe. The mean incubation period for chikungunya is 2 to 4 days and is followed by an acute onset of high fever, headache, photophobia, myalgia, and arthralgias that are often severe.5,6 A maculopapular eruption on the patient’s arms and legs that lasts for 2 to 3 days is present in approximately 50% of cases but is not diagnostic.5 After 1 to 2 weeks, symptoms usually resolve, but some pa-
tients experience extreme fatigue and disabling arthralgias that can persist for weeks, months, or even years. Although mortality is low, it is more likely to occur in the elderly population, neonates, and adults with comorbidities. Asymptomatic infections have been documented. Between 3% and 25% of individuals with serological evidence of CHIKV infection report no obvious symptoms. Diagnosis of chikungunya is based on clinical, epidemiological, and laboratory findings.5,6 Laboratory confirmation of a suspected case is crucial to distinguish it from other viral infections such as dengue, which is also transmitted by Aedes mosquitoes. Currently, there is no commercially available vaccine to prevent infection with CHIKV. The only recommended treatments for CHIKVinduced arthralgias are nonsteroidal anti-inflammatory drugs. Because autochthonous transmission of CHIKV in the United States is likely a “when” rather than an “if,” it is important to implement measures that could lessen the impact of chikungunya. First and most obvious is education of the American public, especially pregnant women, the elderly population, and those with comorbidities, on how to reduce the major risk of CHIKV infection through the use of personal protection (eg, clothing, insect repellent) and environmental measures (eg, elimination of standing water, vector control, screens) to avoid mosquito bites. Second, those experiencing symptoms consistent with chikungunya must be counseled to self-quarantine during the first few days of infection when viral titers in the blood are highest to prevent vector-borne transmission to others. Third, support for research efforts to develop and test vaccines and treatments must be fast tracked. Fourth, surveillance activities must be increased to monitor the spread of chikungunya to enable more effective targeting of vector control efforts. Fifth, a strategy for screening donors and testing all donated blood and tissues must be put in place, particularly because of the possibility of donors with asymptomatic infection.7 If enacted proactively, these measures could help to protect those who are most vulnerable and may allow for a window of opportunity for safety testing of experimental vaccines that are in the pipeline. The recent announcement by the Global Virus Network of the formation of a Chikungunya Task Force that will focus on issues related to vaccines and rapid diagnostic tools to prevent the spread of chikungunya in the Americas is a welcome development (http://gvn.org/chikungunya -task-force/). Hopefully, much of what we learn while confronting CHIKV will be of collateral benefit when other emerging viruses threaten our populace.
(Reprinted) JAMA Dermatology March 2015 Volume 151, Number 3
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a University of California - San Diego User on 06/03/2015
257
Opinion Viewpoint
virus in the United States. PLoS Negl Trop Dis. 2012; 6(11):e1918.
ARTICLE INFORMATION Published Online: October 1, 2014. doi:10.1001/jamadermatol.2014.2034. Conflict of Interest Disclosures: None reported. REFERENCES 1. Fischer M, Staples JE; Arboviral Diseases Branch, National Center for Emerging and Zoonotic Infectious Diseases, CDC. Notes from the field: chikungunya virus spreads in the Americas— Caribbean and South America, 2013-2014. MMWR Morb Mortal Wkly Rep. 2014;63(22):500-501. 2. Ruiz-Moreno D, Vargas IS, Olsen KE, Harrington LC. Modeling dynamic introduction of chikungunya
3. Vega-Rúa A, Zouache K, Girod R, Failloux AB, Lourenço-de-Oliveira R. High level of vector competence of Aedes aegypti and Aedes albopictus from ten American countries as a crucial factor in the spread of chikungunya virus. J Virol. 2014;88 (11):6294-6306. 4. Khan K, Bogoch I, Brownstein JS, et al. Assessing the origin of and potential for international spread of chikungunya virus from the Caribbean. PLoS Curr Outbreaks. 2014;6. doi:10.1371/currents.outbreaks .2134a0a7bf37fd8d388181539fea2da5.
5. Burt FJ, Rolph MS, Rulli NE, Mahalingam S, Heise MT. Chikungunya: a re-emerging virus. Lancet. 2012;379(9816):662-671. 6. Tsetsarkin KA, Chen R, Sherman MB, Weaver SC. Chikungunya virus: evolution and genetic determinants of emergence. Curr Opin Virol. 2011;1 (4):310-317. 7. Gallian P, de Lamballerie X, Salez N, et al. Prospective detection of chikungunya virus in blood donors, Caribbean 2014. Blood. 2014;123(23):36793681.
NOTABLE NOTES
The Portrayal of Albinism in Pop Culture A 360° Change From Previous Ideology Brian James Simmons, BS; Leyre Ainara Falto-Aizpurua, MD; Robert Denison Griffith, MD; Keyvan Nouri, MD
Cultural references to albinism are as old as recorded history. With the discovery of tyrosinase deficiency in animals in 1904 and the first scientific report on albinism 4 years later by Sir Archibald Garrod to lay the groundwork,1 albinism became known as a group of genetic disorders that are characterized by a defect in the production of tyrosinase, which is involved in the production of melanin. However, the way that albinism has been widely portrayed in popular culture, such as in film and fiction, has caused an ominous negative aspect to be associated with this genetic disorder—so much so that a new term has been coined—evil albino— which acts as a plot device.2 The common traits of the evil albino include pale skin, platinum blonde hair, and blue or red eyes. This negative ideology is even present in great works of literature, such as H. G. Wells’s novel The Invisible Man, and in film this came to fruition in the 1960s with the craze in skin tanning and the loss of the ideals associated with pale skin. Here is a short list of a few famous albinos that have appeared on the big screen: Silas in The Da Vinci Code, the twins in The Matrix Reloaded, and of course the most hated villain of all for Hogwarts-loving fans, Lord Voldemort. Even when albinism is portrayed in a positive light, such as in the movie Powder, the character is almost mystical, with the IQ of a genius and the ability to produce electromagnetic charges. Nevertheless, he is kept in a basement, out of sight and out of mind for the world, demonstrating the view that society has regarding albinos. The idea of the evil albino was not always the norm. Asian societies have long valued extremely fair skin. Old Chinese sayings are a testament to this. One such example roughly translates to “One whiteness
258
can cover 3 kinds of ugliness,” and to this day, Chinese continue to use bleach creams and even sunscreen with whiteners.3 In Japan, geisha would use paint in their efforts to obtain very fair completions. In Europe, during the Middle Ages and the Renaissance, fair skin was considered to be attractive and was strived for. It represented wealth and a high aristocratic social status. How has society made such a drastic turn? Historically, albinism would have represented the pinnacle of the fair-skinned ideal and a mark of high status, and now albinism is vilified as a condition that acts as a prerequisite for evil in some of the biggest blockbusters in films and fiction. The attention on albinism should be directed to awareness of its characteristics—not only as having fair skin, but also its associated health concerns, including the visual defects, increased risk of skin cancer, and the psychosocial problems that individuals with albinism endure. Author Affiliations: Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida. Corresponding Author: Brian James Simmons, BS, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 ([email protected]). 1. Rosenberg LE. Legacies of Garrod’s brilliance: one hundred years—and counting. J Inherit Metab Dis. 2008;31(5):574-579. 2. National Organization for Albinism and Hypopigmentation. “Evil Albino” missing from 2004 movies: will “The Da Vinci Code” revive the cliché? http: //www.albinism.org/pressRelease/pressRelease2005-01-06.html. Accessed September 12, 2014. 3. Diaz RI, Cheung D, Lee AP. How to know Hong Kong and Macau: Asia's skin whitening craze. http://scalar.usc.edu/anvc/travel-and-culture-in-hong-kong -and-macau/asias-skin-whitening-craze. Accessed October 10, 2014.
JAMA Dermatology March 2015 Volume 151, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a University of California - San Diego User on 06/03/2015
jamadermatology.com
VIEWPOINT
Lola V. Stamm, PhD Program in Infectious Diseases, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill.
Corresponding Author: Lola V. Stamm, PhD, Department of Epidemiology, University of North Carolina at Chapel Hill, 3103 Hooker Research Center, S Columbia St, Chapel Hill, NC 27599-7435 (lstamm@email .unc.edu). jamadermatology.com
Chikungunya Emerging Threat to the United States Until recently, most Americans had never heard of chikungunya, a mosquito-transmitted disease caused by the chikungunya virus (CHIKV). This has changed as a result of an explosive outbreak of chikungunya throughout the Caribbean that has affected more than 580 000 people since December 2013.1 Although cases of chikungunya have been reported this year in the United States (eg, North Carolina, Florida, Indiana, Nebraska, Tennessee), these have virtually all been in travelers returning from the Caribbean or from chikungunyaendemic areas of Africa or Asia. 1 However, various data suggest that it is only a matter of time until CHIKV transmission is autochthonous in the continental United States and chikungunya becomes a public health problem.2-4 The likelihood of this scenario is heightened because of the presence of (1) CHIKV replication-competent mosquito vectors (ie, Aedes albopictus and Aedes aegypti); (2) a temperate climate, particularly in the southeastern United States, that is conducive to the establishment of endemic foci of chikungunya; (3) a highly susceptible population with no preexisting immunity to the virus; and (4) a large influx of viremic travelers returning from the Caribbean, coupled with the seasonal synchronicity of vector activity. The CHIKV was first isolated in Africa in the early 1950s during an outbreak in southern Tanzania.5,6 Two genetically distinct lineages of the virus have been identified, the west African lineage and the east, central, and south African lineage. The latter lineage includes the Asian genotype that is currently circulating in the Caribbean and is transferred between humans and mosquitoes without the need for animal reservoirs. Before 2000, large outbreaks of chikungunya were relatively rare. However, since 2000, large outbreaks have occurred in Africa and Asia. An outbreak in East Africa in 2004 spread to several islands in the Indian Ocean including Réunion, where in 2005 approximately 35% of the population became ill in only a few months and fatalities were reported. Since then, chikungunya outbreaks in India, Sri Lanka, and Indonesia have sickened millions. In 2007 and 2010, autochthonous transmission of CHIKV was reported for the first time in northern Italy and in southern France, respectively, as a result of the introduction of CHIKV by viremic travelers returning to Europe. The mean incubation period for chikungunya is 2 to 4 days and is followed by an acute onset of high fever, headache, photophobia, myalgia, and arthralgias that are often severe.5,6 A maculopapular eruption on the patient’s arms and legs that lasts for 2 to 3 days is present in approximately 50% of cases but is not diagnostic.5 After 1 to 2 weeks, symptoms usually resolve, but some pa-
tients experience extreme fatigue and disabling arthralgias that can persist for weeks, months, or even years. Although mortality is low, it is more likely to occur in the elderly population, neonates, and adults with comorbidities. Asymptomatic infections have been documented. Between 3% and 25% of individuals with serological evidence of CHIKV infection report no obvious symptoms. Diagnosis of chikungunya is based on clinical, epidemiological, and laboratory findings.5,6 Laboratory confirmation of a suspected case is crucial to distinguish it from other viral infections such as dengue, which is also transmitted by Aedes mosquitoes. Currently, there is no commercially available vaccine to prevent infection with CHIKV. The only recommended treatments for CHIKVinduced arthralgias are nonsteroidal anti-inflammatory drugs. Because autochthonous transmission of CHIKV in the United States is likely a “when” rather than an “if,” it is important to implement measures that could lessen the impact of chikungunya. First and most obvious is education of the American public, especially pregnant women, the elderly population, and those with comorbidities, on how to reduce the major risk of CHIKV infection through the use of personal protection (eg, clothing, insect repellent) and environmental measures (eg, elimination of standing water, vector control, screens) to avoid mosquito bites. Second, those experiencing symptoms consistent with chikungunya must be counseled to self-quarantine during the first few days of infection when viral titers in the blood are highest to prevent vector-borne transmission to others. Third, support for research efforts to develop and test vaccines and treatments must be fast tracked. Fourth, surveillance activities must be increased to monitor the spread of chikungunya to enable more effective targeting of vector control efforts. Fifth, a strategy for screening donors and testing all donated blood and tissues must be put in place, particularly because of the possibility of donors with asymptomatic infection.7 If enacted proactively, these measures could help to protect those who are most vulnerable and may allow for a window of opportunity for safety testing of experimental vaccines that are in the pipeline. The recent announcement by the Global Virus Network of the formation of a Chikungunya Task Force that will focus on issues related to vaccines and rapid diagnostic tools to prevent the spread of chikungunya in the Americas is a welcome development (http://gvn.org/chikungunya -task-force/). Hopefully, much of what we learn while confronting CHIKV will be of collateral benefit when other emerging viruses threaten our populace.
(Reprinted) JAMA Dermatology March 2015 Volume 151, Number 3
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a University of California - San Diego User on 06/03/2015
257
Opinion Viewpoint
virus in the United States. PLoS Negl Trop Dis. 2012; 6(11):e1918.
ARTICLE INFORMATION Published Online: October 1, 2014. doi:10.1001/jamadermatol.2014.2034. Conflict of Interest Disclosures: None reported. REFERENCES 1. Fischer M, Staples JE; Arboviral Diseases Branch, National Center for Emerging and Zoonotic Infectious Diseases, CDC. Notes from the field: chikungunya virus spreads in the Americas— Caribbean and South America, 2013-2014. MMWR Morb Mortal Wkly Rep. 2014;63(22):500-501. 2. Ruiz-Moreno D, Vargas IS, Olsen KE, Harrington LC. Modeling dynamic introduction of chikungunya
3. Vega-Rúa A, Zouache K, Girod R, Failloux AB, Lourenço-de-Oliveira R. High level of vector competence of Aedes aegypti and Aedes albopictus from ten American countries as a crucial factor in the spread of chikungunya virus. J Virol. 2014;88 (11):6294-6306. 4. Khan K, Bogoch I, Brownstein JS, et al. Assessing the origin of and potential for international spread of chikungunya virus from the Caribbean. PLoS Curr Outbreaks. 2014;6. doi:10.1371/currents.outbreaks .2134a0a7bf37fd8d388181539fea2da5.
5. Burt FJ, Rolph MS, Rulli NE, Mahalingam S, Heise MT. Chikungunya: a re-emerging virus. Lancet. 2012;379(9816):662-671. 6. Tsetsarkin KA, Chen R, Sherman MB, Weaver SC. Chikungunya virus: evolution and genetic determinants of emergence. Curr Opin Virol. 2011;1 (4):310-317. 7. Gallian P, de Lamballerie X, Salez N, et al. Prospective detection of chikungunya virus in blood donors, Caribbean 2014. Blood. 2014;123(23):36793681.
NOTABLE NOTES
The Portrayal of Albinism in Pop Culture A 360° Change From Previous Ideology Brian James Simmons, BS; Leyre Ainara Falto-Aizpurua, MD; Robert Denison Griffith, MD; Keyvan Nouri, MD
Cultural references to albinism are as old as recorded history. With the discovery of tyrosinase deficiency in animals in 1904 and the first scientific report on albinism 4 years later by Sir Archibald Garrod to lay the groundwork,1 albinism became known as a group of genetic disorders that are characterized by a defect in the production of tyrosinase, which is involved in the production of melanin. However, the way that albinism has been widely portrayed in popular culture, such as in film and fiction, has caused an ominous negative aspect to be associated with this genetic disorder—so much so that a new term has been coined—evil albino— which acts as a plot device.2 The common traits of the evil albino include pale skin, platinum blonde hair, and blue or red eyes. This negative ideology is even present in great works of literature, such as H. G. Wells’s novel The Invisible Man, and in film this came to fruition in the 1960s with the craze in skin tanning and the loss of the ideals associated with pale skin. Here is a short list of a few famous albinos that have appeared on the big screen: Silas in The Da Vinci Code, the twins in The Matrix Reloaded, and of course the most hated villain of all for Hogwarts-loving fans, Lord Voldemort. Even when albinism is portrayed in a positive light, such as in the movie Powder, the character is almost mystical, with the IQ of a genius and the ability to produce electromagnetic charges. Nevertheless, he is kept in a basement, out of sight and out of mind for the world, demonstrating the view that society has regarding albinos. The idea of the evil albino was not always the norm. Asian societies have long valued extremely fair skin. Old Chinese sayings are a testament to this. One such example roughly translates to “One whiteness
258
can cover 3 kinds of ugliness,” and to this day, Chinese continue to use bleach creams and even sunscreen with whiteners.3 In Japan, geisha would use paint in their efforts to obtain very fair completions. In Europe, during the Middle Ages and the Renaissance, fair skin was considered to be attractive and was strived for. It represented wealth and a high aristocratic social status. How has society made such a drastic turn? Historically, albinism would have represented the pinnacle of the fair-skinned ideal and a mark of high status, and now albinism is vilified as a condition that acts as a prerequisite for evil in some of the biggest blockbusters in films and fiction. The attention on albinism should be directed to awareness of its characteristics—not only as having fair skin, but also its associated health concerns, including the visual defects, increased risk of skin cancer, and the psychosocial problems that individuals with albinism endure. Author Affiliations: Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida. Corresponding Author: Brian James Simmons, BS, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136 ([email protected]). 1. Rosenberg LE. Legacies of Garrod’s brilliance: one hundred years—and counting. J Inherit Metab Dis. 2008;31(5):574-579. 2. National Organization for Albinism and Hypopigmentation. “Evil Albino” missing from 2004 movies: will “The Da Vinci Code” revive the cliché? http: //www.albinism.org/pressRelease/pressRelease2005-01-06.html. Accessed September 12, 2014. 3. Diaz RI, Cheung D, Lee AP. How to know Hong Kong and Macau: Asia's skin whitening craze. http://scalar.usc.edu/anvc/travel-and-culture-in-hong-kong -and-macau/asias-skin-whitening-craze. Accessed October 10, 2014.
JAMA Dermatology March 2015 Volume 151, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a University of California - San Diego User on 06/03/2015
jamadermatology.com
