Miscellaneous mosquito-borne diseases

Last updated: July 8, 2022

Summary

Mosquito-borne diseases are a group of viral infections transmitted by the bite of an infected mosquito, typically from the Culex, Anopheles, or Aedes species. Vertical and human-to-human transmission (e.g., via blood transfusions, organ, and tissue transplants) are also possible. These viral diseases belong to three main families: Togaviridae (Chikungunya virus, Eastern equine encephalitis (EEEV), Western equine encephalitis (WEEV), Flaviviridae (West Nile virus, Dengue virus, Zika virus, Yellow fever virus, Japanese encephalitis virus), and Bunyaviridae (Rift Valley fever virus, La Crosse encephalitis virus). Clinical features of these diseases vary but often include an initial systemic febrile illness (i.e., fever, headache, myalgias, gastrointestinal symptoms) that progresses to a neuroinvasive disease (e.g., meningitis, encephalitis). Diagnosis is made via antibody detection (e.g., IgM, IgG), ELISA, FIA, or PCR. Treatment is typically supportive. Prevention primarily consists of mosquito control measures (i.e., adequate clothing, insect repellents, mosquito nets, minimizing mosquito breeding).

Mosquito-borne Togavirus diseases

Overview

Overview of mosquito-borne Togavirus diseases
	Geography	Incubation period	Clinical features	CSF analysis
Chikungunya fever	Found primarily in tropical and subtropical regions (e.g., Middle and South America, sub-Saharan Africa, Southeast Asia)	3–7 days	Fever, malaise Headache Lymphadenopathy Severe bilateral polyarthralgia Periarticular edema Maculopapular rash	Normal
Eastern equine encephalitis (EEE)	Found primarily in the Americas In the US, occurs east of the Mississippi River (e.g., New York, New Jersey, Michigan)	4–10 days	Systemic febrile illness (acute EEE) Fever Headache GI symptoms EEE Seizures Confusion Focal disabilities Coma	↑ Neutrophils and proteins Normal or ↓ glucose
Western equine encephalitis (WEE)	Occurs on the West Coast of the United States and Canada	2–7 days	Mostly asymptomatic Systemic febrile illness (acute WEE) Fever Headache Myalgias Malaise GI symptoms WEE Seizures Confusion, Somnolence Spasticity Cognitive impairment Coma	↑ Opening pressure ↑ Lymphocytes and proteins Normal glucose
Venezuelan equine encephalitis (VEE)	Found predominantly in the Americas (Colombia, Venezuela, Panama, Guatemala, Mexico, the United States, Ecuador, Nicaragua, Costa Rica, Peru)	2–5 days	Systemic febrile illness (acute VEE) Fever Headache Myalgias, arthralgias Sore throat Retroorbital pain GI symptoms Venezuelan equine encephalitis Seizures Confusion Motor and cognitive impairment Focal disabilities	↑ Lymphocytes, proteins ↑ Glucose
Ross River fever (RRF)	Found predominantly in Australia, Papua New Guinea, the Solomon Islands, and other parts of Southeast Asia	3–9 days	Febrile illness Usually self-limited Classic triad: fever, rash, and arthritis Other clinical manifestations Hematuria and/or glomerulonephritis Splenomegaly Meningoencephalitis	Normal
Barmah Forest virus disease	Found in Australia and Papua New Guinea	7–10 days	Febrile illness Fever Malaise Rash Arthritis Other clinical manifestations Glomerulonephritis Meningoencephalitis	Normal

Chikungunya fever ^[1]^[2]

Epidemiology
- Found primarily in tropical and subtropical regions (e.g., Middle and South America, sub-Saharan Africa, Southeast Asia)
- Outbreaks occur sporadically.
Etiology
- Pathogen: Chikungunya virus (belongs to the alphavirus genus of the family Togaviridae)
- Vectors: mosquitoes (Aedes aegypti and Aedes albopictus), possibly leading to coinfection with dengue
- Reservoirs: nonhuman or human primates
- Route of transmission: Mosquito bite
- Clinical features
  - Incubation period: usually 3–7 days
  - Fever, malaise
  - Headache
  - Lymphadenopathy
  - Severe bilateral polyarthralgia
  - Periarticular edema
  - Maculopapular rash
Diagnostics
- History of recent travel to tropical and subtropical regions
- Serology and RT-PCR
Differential diagnosis
- Dengue fever and other viral hemorrhagic fevers
- Malaria
- Zika virus infection
Treatment: supportive
Complication: chronic arthritis
- Most common and severe complication
- May last for months to years and lead to long-term disability
Prognosis: Most individuals fully recover within a week.

Eastern equine encephalitis (EEE)

Epidemiology
- Found primarily in the Americas
- In the US, occurs east of the Mississippi River (e.g., New York, New Jersey, Michigan)
- Bimodal distribution
  - ≤ 5 years of age
  - ≥ 60 years of age
- Outbreaks occur from late spring to early fall.
Etiology
- Pathogen: Eastern equine encephalitis virus (EEEV)
- Vectors: mosquitoes (Culiseta melanura, Aedes, Coquillettidia, and Culex spp.)
- Reservoirs: horses, birds
- Route of transmission
  - Mosquito bite
  - Human-to-human: organ transplantation
Clinical features
- Incubation period: 4–10 days ^[3]
- Systemic febrile illness (acute EEE)
  - Lasts up to 14 days ^[3]
  - Fever
  - Headache
  - Gastrointestinal symptoms (nausea, vomiting)
- EEE
  - A life-threatening inflammation of the CNS
  - Occurs in ∼ 5% of patients ^[3]
  - Seen shortly after systemic febrile illness
  - Neurological symptoms include seizures, confusion, focal disabilities (cranial nerve palsies), and coma.
Diagnostics
- Laboratory studies: ↑ WBCs
- Serology (gold standard)
  - IgM and/or rising levels of IgG antibodies detected using ELISA, IFA, or hemagglutination assays
  - Confirmation: ≥ 4-fold antibody titer increase in serum samples collected after the first week of symptoms
- Reverse transcriptase PCR
- PRNT
- CSF analysis
  - ↑ Neutrophils and proteins
  - Normal or decreased glucose
  - Analyzed using ELISA test for EEV-specific antibodies
- Brain MRI
- Viral culture
Differential diagnosis
- Aseptic meningitis
- Viral encephalitis (e.g., measles, echovirus)
Treatment: mainly supportive
- Analgesics for pain and fever
- Management of fluids and electrolyte balance
- Maintenance of blood pressure and oxygenation
- Anticonvulsive treatment for seizures
Complications
- Severe neurological sequelae ^[4]
- Epilepsy
- Cognitive disabilities
- Behavioral changes
- Death: occurs within 5 days of diagnosis ^[4]

Western equine encephalitis (WEE)

Epidemiology
- Occurs on the West Coast of the United States and Canada
- Outbreaks during summer
Etiology
- Pathogen: Western equine encephalitis virus (WEEV)
- Vectors: mosquitoes (Culex tarsalis, Aedes spp.)
- Reservoirs: horses, mules, birds
- Route of transmission
  - Mosquito bite
  - Human-to-human
    - Blood transfusions from an infected host
    - Transplacental
Clinical features
- Incubation period: 2–7 days ^[5]
- Most affected individuals are asymptomatic.
- Systemic febrile illness (acute WEE)
  - Fever
  - Headache
  - Myalgias
  - Malaise, fatigue
  - Gastrointestinal symptoms (nausea, vomiting)
- WEE
  - Adults have more mild symptoms than children and elderly individuals.
  - Severe forms of encephalitis are more common in children.
  - Neurological symptoms include seizures, confusion, somnolence, spasticity, cognitive impairment, and coma.
Diagnostics
- Laboratory studies: ↑ WBCs
- Serology
  - IgM and/or rising levels of IgG antibodies detected using ELISA, IFA, or hemagglutination assays
  - Confirmation: ≥ 4-fold antibody titer increase in serum samples collected after the first week of symptoms
- Reverse transcriptase PCR
- PRNT
- CSF analysis
  - ↑ Opening pressure, lymphocytes, and proteins
  - Normal glucose
  - Analyzed using ELISA test for WEEV-specific antibodies
- Brain MRI
- Viral culture
Differential diagnosis
Treatment: mainly supportive
- Analgesics for pain and fever
- Management of fluids and electrolyte balance
- Maintenance of blood pressure and oxygenation
- Anticonvulsive treatment of seizures
Complications
- Neurological sequelae
- Epilepsy
- Spasticity
- Behavioral changes
- Death

Venezuelan equine encephalitis (VEE)

Epidemiology
- Found predominantly in the Americas (Colombia, Venezuela, Panama, Guatemala, Mexico, the United States, Ecuador, Nicaragua, Costa Rica, Peru)
- Sporadic outbreaks
Etiology
- Pathogen
  - Venezuelan equine encephalitis virus (VEEV)
  - Subtypes IAB and IC are responsible for VEE in humans.
- Vectors: mosquitoes (Ochlerotatus taeniorhynchus, Ae. sollicitans, and Ae. taeniorhynchus transmit epizootic strains )
- Reservoirs: horses, mules, donkeys, rodents
- Route of transmission
  - Mosquito bite
  - Inhalation of aerosols
  - Human-to-human: vertical transmission
Clinical features
- Incubation period: 2–5 days ^[6]
- Systemic febrile illness (acute VEE)
  - Lasts 3–4 days ^[6]
  - Fever
  - Headache
  - Myalgias, arthralgias
  - Sore throat
  - Retroorbital pain
  - Gastrointestinal symptoms (nausea, vomiting)
- Venezuelan equine encephalitis
  - Manifests in ≤ 15% of patients ^[6]
  - Severe forms of encephalitis are more common in children.
  - Neurological symptoms include seizures, confusion, motor and cognitive impairment, and focal disabilities.
Diagnostics
- Laboratory studies
  - CBC: leukopenia, lymphopenia
  - LFTs: ↑ transaminases
- Serology (gold standard)
  - IgM and/or rising levels of IgG antibodies detected using ELISA, IFA, or hemagglutination assays
  - Confirmation: ≥ 4-fold antibody titer increase in serum samples collected
- Reverse transcriptase PCR
  - Blood or pharyngeal sample
  - Can be performed on the 8^th day after symptom onset
- PRNT
- CSF analysis: ↑ lymphocytes, proteins, and glucose
- Analyzed using ELISA test for VEEV-specific antibodies
- EEG: diffuse slowing activity
- Viral culture
Differential diagnosis
- Dengue fever
- Chikungunya fever
- EEE
- Zika
- HSV encephalitis
Treatment: mainly supportive
- Analgesics for pain and fever
- Management of fluids and electrolyte balance
- Maintenance of blood pressure and oxygenation
- Anticonvulsive treatment of seizures
Complications
- Neurological sequelae
  - Cognitive disabilities
  - Behavioral changes
- Pregnant women
- Death

Ross River fever (RRF)

Epidemiology
- Found predominantly in Australia, Papua New Guinea, the Solomon Islands, and other parts of Southeast Asia
- Outbreaks during summer and early autumn
Etiology
- Pathogen: Ross River virus (RRV)
- Vectors: mosquitoes (Aedes vigilax, Aedes camptorhynchus, Culex annulirostris, and Aedes aegypti)
- Reservoirs: wallabies, kangaroos, possums, horses
- Route of transmission
  - Mosquito bite
  - Human-mosquito-human transmission
  - Human-to-human: blood transfusions from an infected host
Clinical features
- Incubation period: 3–9 days ^[7]
- Febrile illness
  - Usually self-limited
  - Classic triad: fever, rash, and arthritis
    - Fever of ≥ 9°C, may last up to 3 days ^[7]
    - Maculopapular rash, affecting the trunk, arms, palms, soles, and face.
    - Arthritis is symmetrical, mainly involving the knees, ankles, wrists, and fingers.
  - Generalized fatigue, myalgias, and lymphadenopathies are also common.
- Other clinical manifestations
  - Hematuria and/or glomerulonephritis
  - Splenomegaly
  - Meningoencephalitis
Diagnostics
- Laboratory studies: ↑ ESR
- Serology (gold standard): IgM and/or rising levels of IgG antibodies detected using ELISA
- PCR
- Viral culture
Differential diagnosis
- Barmah Forest virus
- Chikungunya virus
Treatment: mainly supportive
- Analgesics for pain and fever
- Management of fluids and electrolyte balance
- Maintenance of blood pressure and oxygenation
- Anticonvulsive treatment of seizures
Complications
- Persistent symptoms (arthritis, fatigue) ^[8]
- Septic arthritis

Mosquito-borne Flavivirus diseases

Overview of mosquito-borne Flavivirus diseases
		West Nile virus fever	Murray Valley encephalitis (MVE)	St. Louis encephalitis
Epidemiology		One of the most widely distributed arboviruses Endemic in Africa, parts of Europe, South Asia, Australia, the United States, and the Middle East Outbreaks during summer and fall	Found in Australia, Papua New Guinea, and Indonesia Sporadic outbreaks	Found in North, Central, and South America Outbreaks during summer
Etiology	Pathogen	West Nile virus Kunjin virus (subtype of West Nile virus)	MVE virus	St. Louis encephalitis virus
	Vectors	Mosquitoes (Culex, Aedes, or Anopheles spp.)	Mosquitoes (Culex spp.)	Mosquitoes (Culex spp.)
	Reservoirs	Mosquitoes, birds, horses, dogs	Mosquitoes, birds	Mosquitoes, birds
	Route of transmission	Mosquito bite Human-to-human Blood transfusion Organ and tissue transplant Transplacental ^[9]	Mosquito bite	Mosquito bite
Incubation period		2–14 days ^[10]	1–4 weeks ^[11]	4–21 days ^[12]
Clinical features		∼ 80% of affected individuals are asymptomatic. ^[13] Symptomatic disease Usually self-limited (3–10 days) ^[10] Fever, headache, malaise, myalgias Gastrointestinal symptoms (e.g., nausea, vomiting, anorexia) Rash: transient maculopapular rash on the trunk and extremities Ophthalmological symptoms (e.g., orbital pain, conjunctivitis) Neuroinvasive disease Seen in ∼ 1% of cases ^[13] Risk factors Age ≥ 60 years CCR5 deficiency Hematological malignancies Hypertension Diabetes mellitus Immunosuppression Manifests as fever with: Meningitis (headache, meningismus) OR Encephalitis (altered mental status, myoclonus of the upper extremities, bradykinesia, rigidity, cognitive difficulties) OR Acute flaccid paralysis (asymmetrical weakness of lower extremities within 48 hours of symptom onset)	Most affected individuals are asymptomatic. Prodromal illness (∼ 1:1,000 infections) ^[11] Headache Fever Gastrointestinal symptoms (e.g., nausea, vomiting, anorexia) Myalgias Neurological symptoms Manifest 2–5 days after the prodromal phase ^[11] Drowsiness, irritability, confusion, and meningismus Severe neurological cases: seizures, hyperreflexia, and coma	Most affected individuals are asymptomatic. Illness only manifests in ∼ 1% of affected individuals. ^[12] Age is the most important risk factor for the development of symptomatic disease (more common in individuals > 60 years of age). Prodromal illness Severe headache Fever 40–41°C Gastrointestinal symptoms (e.g., nausea, vomiting, anorexia) Myalgias Respiratory symptoms (e.g., cough, odynophagia) Urinary tract symptoms (e.g., incontinence, dysuria) SLE/aseptic meningitis Children have more mild symptoms. Neurological symptoms include drowsiness, irritability, confusion, tremors, ataxia, and meningismus.
Diagnostics	Laboratory studies	CBC: ↑ WBCs	CBC: ↑ WBCs	CBC: ↑ WBCs LFTs: ↑ ALT Other: ↑ creatine kinase Urinalysis: proteinuria, hematuria, pyuria
	Confirmatory tests	Serology Gold standard MAC-ELISA to detect IgM antibodies Performed on the 8^th day after symptom onset PRNT PCR	Serology Gold standard IgM and/or rising levels of IgG antibodies detected using ELISA Confirmation: ≥ 4-fold antibody titer increase in serum samples collected Continuous increase in IgG titers can be seen in convalescent patients. PRNT PCR	Serology Gold standard IgM and/or rising levels of IgG antibodies detected using ELISA PCR
	Lumbar puncture (CSF analysis)	↑ Lymphocytes and proteins Normal glucose levels Analyzed using MAC-ELISA test for detection of specific IgM antibodies	↑ Lymphocytes and proteins Normal glucose levels Analyzed using ELISA test for MVE-specific antibodies	↑ Opening pressure, lymphocytes, and proteins Normal or decreased glucose level Analyzed using ELISA test for SLE-specific antibodies
	Brain MRI	Normal or demonstrates nonspecific changes (increased signal intensity)	Hyperintensity areas in T2, affecting thalami and brainstem	Normal or demonstrates nonspecific changes
	Other	EEG: generalized, continuous slowing Electromyography and nerve conduction studies Show normal conduction speed and decreased compound motor action potentials Help to differentiate from Guillain-Barré syndrome	Viral culture	EEG: shows slow delta wave activity Viral culture
Differential diagnosis		Dengue Japanese encephalitis Powassan virus	Japanese encephalitis	West Nile virus Herpes encephalitis
Treatment		Supportive Management of fluids and electrolyte balance Analgesics for pain and fever Maintenance of blood pressure and oxygenation Antiemetics for nausea and vomiting	Supportive Management of fluids and electrolyte balance Anticonvulsive treatment of seizures	Supportive Management of fluids and electrolyte balance Antiemetics for nausea and vomiting Analgesics for pain and fever Maintenance of blood pressure and oxygenation Interferon α-2b can be considered if the patient shows no improvement.
Complications		Persistent symptoms Occur after the acute period Fatigue, weakness, loss of balance, memory loss, impaired motor skills, and attention abnormalities Ocular manifestations (retinal hemorrhages, vitritis, chorioretinitis) Rhabdomyolysis Hepatitis Pancreatitis Myocarditis Central diabetes insipidus Coma and death (due to neuroinvasive disease) Guillain-Barré syndrome (rare)	Permanent neurological deficits (∼ 50% of symptomatic individuals) ^[14] Death (∼ 33% of patients with neurological symptoms) ^[14]	SIADH Neurological sequelae Death

See also “Yellow fever,” “Dengue,” “Zika virus infection,” and “Japanese encephalitis.”

Mosquito (Aedes aegypti)

Mosquito-borne Bunyavirus diseases

Overview of mosquito-borne Bunyavirus diseases
		La Crosse encephalitis	Rift Valley fever
Epidemiology		Found in the midwestern, central, and southeastern parts of the United States Common in children (1–15 years of age) ^[15] Outbreaks during the summer	Found in Egypt, Sub-Saharan Africa, and the Arabian Peninsula Sporadic outbreaks
Etiology	Pathogen	La Crosse virus, a California serogroup virus, an Orthobunyavirus	Rift Valley fever virus (RVFV), a Phlebovirus
	Vectors	Mosquito: Aedes triseriatus (tree hole mosquito)	Mosquito (Aedes and Culex spp.)
	Reservoirs	Chipmunks, foxes, squirrels, woodchucks	Cattle, sheep, goats, camels
	Route of transmission	Mosquito bite	Mosquito bite Direct contact with blood or tissues of infected animals Inhalation of aerosols from infected animal tissue
Incubation period		5–15 days ^[15]	2–6 days ^[16]
Clinical features		Most affected individuals are asymptomatic.
Clinical features		Systemic febrile illness Fever Headache Gastrointestinal symptoms (nausea and vomiting) Fatigue Lethargy La Crosse encephalitis Seizures Focal deficits (e.g., Babinski sign) Confusion Aseptic meningitis Cognitive impairment	Rift Valley fever Typically lasts up to 7 days ^[16] Fever Headache Myalgias Photophobia Gastrointestinal symptoms (e.g., anorexia, vomiting, diarrhea) Severe forms (∼ 8–10%) ^[16] Ocular Manifests up to 3 weeks after symptom onset Symptoms include scotomas, blurred and decreased vision. Meningoencephalitis Manifests up to 4 weeks after symptom onset Symptoms include severe headache, confusion, seizures, and coma. Hemorrhagic fever (≤ 1%) Occurs within 4 days of symptom onset Symptoms include bleeding of skin and mucosa (e.g., purpura, gingivorrhagia, epistaxis), jaundice, hematochezia, and hematemesis.
Diagnostics	Laboratory studies	CBC: ↑ WBCs Electrolytes: can show hyponatremia	CBC: ↑ WBCs
	Confirmatory tests	Serology Gold standard IgM and/or rising levels of IgG antibodies detected using ELISA Confirmation: ≥ 4-fold antibody titer increase in serum samples collected 2 weeks after symptom onset	Serology Gold standard IgM and/or rising levels of IgG antibodies detected using ELISA or IFA Reverse transcriptase PCR
	Lumbar puncture	CSF analysis ↑ Lymphocytes and proteins Normal glucose levels Analyzed using IFA for detection of specific IgM antibodies	CSF analysis ↑ Lymphocytes Normal glucose and protein levels Analyzed using IFA for detection of specific RVFV-IgM antibodies
	Other	EEG: shows slowing, epileptiform discharges	Viral culture
Differential diagnosis		HSV encephalitis SLE West Nile virus encephalitis WEE Chikungunya	Malaria Yellow fever Typhoid fever
Treatment		Supportive Management of fluids and electrolyte balance Antiemetics for associated nausea and vomiting Analgesics for pain and fever Maintenance of blood pressure and oxygenation Anticonvulsive treatment of seizures
Complications		Acute Hyponatremia Cerebral edema Coma and death Chronic Neurological sequelae: cognitive, behavioral, and motor skill deficits Epilepsy	Vision loss Neurological sequelae Death Seen in ∼ 50% of patients with hemorrhagic fever form ^[16] Typically due to shock or hepatic insufficiency

Prevention

Mosquito bite prevention

Clothing
- Wear light-colored clothing.
- Long-sleeved shirts and long pants
Insect repellent
- Use insect repellants (e.g., DEET, permethrin, oil of lemon eucalyptus)
- Apply to clothing and footwear.
Mosquito nets
- Place screens at doors and windows.
- Use mosquito nets on baby strollers, carriers, and cribs.
Remove open water containers, trash containers, and water-holding plants to minimize mosquito breeding.

Obligation to report

Mosquito-borne diseases are nationally notifiable diseases in most countries worldwide (i.e., the physician is required by law to report cases of such diseases).

References

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Ojeda Rodriguez JA; Haftel A; Walker JR III.. Chikungunya Fever. StatPearls. 2020.
Banda C, Samanta D. Eastern Equine Encephalitis. StatPearls. 2020.
Eastern Equine Encephalitis (EEE). https://www.cdc.gov/easternequineencephalitis/. Updated: October 7, 2020. Accessed: October 8, 2020.
Simon LV, Coffey R, Fischer MA. Western Equine Encephalitis. StatPearls. 2020.
Crosby B, Crespo ME. Venezuelan Equine Encephalitis. StatPearls. 2020.
Harley D, Sleigh A, Ritchie S. Ross River virus transmission, infection, and disease: a cross-disciplinary review.. Clin Microbiol Rev. 2001; 14 (4): p.909-32, table of contents.doi: 10.1128/CMR.14.4.909-932.2001 . | Open in Read by QxMD
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Alpert SG, Fergerson J, Noël L-P. Intrauterine West Nile virus: ocular and systemic findings. Am J Ophthalmol. 2003; 136 (4): p.733-735.doi: 10.1016/s0002-9394(03)00452-5 . | Open in Read by QxMD
Clark MB, Schaefer TJ. West Nile Virus. StatPearls. 2020.
Mackenzie JS, Lindsay MD, Coelen RJ, Broom AK, Hall RA, Smith DW. Arboviruses causing human disease in the Australasian zoogeographic region.. Arch Virol. 1994; 136 (3-4): p.447-67.doi: 10.1007/BF01321074 . | Open in Read by QxMD
Saint Louis Encephalitis. https://www.cdc.gov/sle/technical/symptoms.html. Updated: December 4, 2018. Accessed: December 9, 2020.
Drebot MA, Artsob H. West Nile virus. Update for family physicians.. Canadian Family Physician. 2005; 51: p.1094-9.
Selvey LA, Speers DJ, Smith DW. Long-term outcomes of Murray Valley encephalitis cases in Western Australia: what have we learnt?. Intern Med J. 2016; 46 (2): p.193-201.doi: 10.1111/imj.12962 . | Open in Read by QxMD
Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Elsevier Saunders ; 2015
Petersen LR. Arthropod-Borne Encephalitides. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/arthropod-borne-encephalitides. Last updated: August 14, 2017. Accessed: December 11, 2017.
Richards MJ. Ross River Virus Infection. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/ross-river-virus-infection. Last updated: January 18, 2018. Accessed: January 9, 2019.
Petersen LR. Epidemiology and Pathogenesis of West Nile Virus Infection. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-west-nile-virus-infection. Last updated: July 30, 2018. Accessed: January 9, 2019.
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