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The 2012 West Nile encephalitis epidemic in Dallas, Texas.

IMPORTANCE
After progressive declines over recent years, in 2012 West Nile virus epidemics resurged nationwide, with the greatest number of cases centered in Dallas County, Texas.


OBJECTIVE
To analyze the epidemiologic, meteorologic, and geospatial features of the 2012 Dallas West Nile virus epidemic to guide future prevention efforts.


DESIGN, SETTING, AND PATIENTS
Public health surveillance of Dallas County, an area of 2257 km2 and population of 2.4 million. Surveillance data included numbers of residents diagnosed with West Nile virus infection between May 30, 2012, and December 3, 2012; mosquito trap results; weather data; and syndromic surveillance from area emergency departments.


MAIN OUTCOMES AND MEASURES
Incidence and age-adjusted incidence rates of West Nile neuroinvasive disease (WNND), daily prevalence of emergency department visits for asthma and skin rash, and Culex quinquefasciatus species-specific vector index (an estimate of the average number of West Nile virus-infected mosquitoes per trap-night).


RESULTS
The investigation identified 173 cases of WNND, 225 of West Nile fever, 17 West Nile virus-positive blood donors, and 19 deaths in 2012. The incidence rate for WNND was 7.30 per 100,000 residents in 2012, compared with 2.91 per 100,000 in 2006, the largest previous Dallas County outbreak. An unusually rapid and early escalation of large numbers of human cases closely followed increasing infection trends in mosquitoes. The Cx quinquefasciatus species-specific vector index predicted the onset of symptoms among WNND cases 1 to 2 weeks later (count regression β = 2.97 [95% CI, 2.34 to 3.60]; P < .001). Although initially widely distributed, WNND cases soon clustered in neighborhoods with high housing density in the north central area of the county, reflecting higher vector indices and following geospatial patterns of West Nile virus in prior years. During the 11 years since West Nile virus was first identified in Dallas, the log-transformed annual prevalence of WNND was inversely associated with the number of days with low temperatures below 28°F (-2.2°C) in December through February (β = -0.29 [95% CI, -0.36 to -0.21]; P < .001). Aerial insecticide spraying was not associated with increases in emergency department visits for respiratory symptoms (β = -4.03 [95% CI, -13.76 to 5.70]; P = .42) or skin rash (β = -1.00 [95% CI, -6.92 to 4.92]; P = .74).


CONCLUSIONS AND RELEVANCE
Large West Nile virus epidemics in Dallas County begin early after unusually warm winters, revisit similar geographical distributions, and are strongly predicted by the mosquito vector index. Consideration of weather patterns and historical geographical hot spots and acting on the vector index may help prevent West Nile virus-associated illness.