► Health Information LibraryIn-Depth ReportsViral encephalitis

Viral encephalitis


An in-depth report on the causes, diagnosis, treatment, and prevention of viral encephalitis.

Alternative Names

West Nile virus



Encephalitis is an infection of the brain, most commonly caused by a virus. The main causes of viral encephalitis are:

  • Herpes viruses, particularly herpes simplex virus
  • Arboviruses, particularly West Nile virus


Symptoms of viral encephalitis appear within several days to weeks of exposure to the virus. Some people who are infected do not develop any symptoms at all. However, most develop headache, "photophobia" (sensitivity to bright light), weakness, nausea, or sleepiness. Those with a severe case of encephalitis may develop:

  • High Fever
  • Severe Headache
  • Stiff neck and back
  • Vomiting
  • Drowsiness and confusion
  • Seizures
  • Behavior changes
  • Muscle weakness
  • Partial paralysis
  • Loss of consciousness


Because encephalitis can on rare occasions be dangerous, it needs to be diagnosed and treated promptly. Treatment for mild cases focuses primarily on supportive care. If herpes is a possible cause, the standard treatment is the antiviral drug acyclovir. Unfortunately, for most other viruses causing encephalitis, including cases caused by West Nile virus and other arboviruses, antiviral drugs are not available.


Arboviruses, the most common cause of encephalitis, are transmitted by blood-sucking insects such as mosquitoes and, less commonly, ticks. The best way to prevent infection with a mosquito-borne virus is to avoid being bitten. Use insect repellant when you go outside, especially during the peak mosquito hours of dusk and dawn. Remove mosquito-breeding environments such as stagnant water from your property.


Encephalitis is an uncommon but potentially life-threatening infection 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, protozoa, or as a complication from other infectious diseases. This report focuses on viral encephalitis.

Many viruses can cause encephalitis. In the United States, the most common viral causes of encephalitis are arboviruses, enteroviruses, and coxsackieviruses. Less commonly, but potentially of greater severity, both herpes simplex virus and West Nile virus can cause encephalitis.

Specific Viruses Associated with Encephalitis

In the United States, the viruses that cause encephalitis 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. In the U.S., West Nile virus is the most common mosquito-borne cause of encephalitis. 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 potentially cause severe brain damage, but can be treated with antiviral medication.
  • Additional viral causes of encephalitis include adenoviruses, enteroviruses, HIV, poliovirus, and viruses associated with childhood diseases such as measles, mumps, and rubella. Rabies, although very rare in the United States, also causes encephalitis.

Viruses and Inflammatory Diseases of the Central Nervous System

Viral infections can cause inflammation in multiple areas of the central nervous system, the area of the body that contains the brain and spinal cord.

Many people exposed to encephalitis-causing viruses have no symptoms. Others may experience a mild transient illness, but do not develop full-blown encephalitis. People with mild encephalitis generally recover spontaneously over a period of several weeks.

Severe cases of encephalitis can, however, have devastating effects, including:

  • Swelling of the brain caused by excess fluid (cerebral edema)
  • Bleeding within the brain (intercerebral hemorrhage)
  • Nerve damage (neuropathy)

Such severe encephalitis can be fatal. Many survivors of severe encephalitis have long-term mental or physical problems, depending on the specific areas of the brain affected. Fortunately, this is quite uncommon.


Herpes Viruses

The herpes virus family includes at least 8 distinct viruses that cause infections in humans. These viruses 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 (HSV) is the most common cause of encephalitis.

HSV is responsible for about 10% of encephalitis cases. Herpes simplex encephalitis (HSE) can be caused by either a new HSV infection or reactivation of a latent pre-existing herpes infection. HSE tends to be most severe when it affects young children and older people. Most adults who contract HSE are older than age 50.

There are two distinct types of the herpes simplex virus:

  • Herpes simplex virus 1 (HSV-1) causes most cases of herpes encephalitis in children and adults. 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. The virus is transmitted from an infected mother during childbirth. HSV-2 is the main cause of genital herpes but it can also cause oral herpes infections.

Herpes simplex encephalitis is the only type of viral encephalitis that is treatable. Drug treatment with acyclovir must be administered promptly, as soon as the infection is considered. If left untreated, herpes simplex encephalitis can be fatal.


Arboviruses, including the West Nile virus, are transmitted by blood-sucking insects such as mosquitoes and ticks. West Nile virus initially develops in birds, which function as the reservoir of infection. Mosquitoes transmit the virus when they bite a susceptible host such as an animal or a human. (The mosquito itself remains quite healthy.) 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 for ARthropod-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 very small number of West Nile virus infections 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 among 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, in particular, 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 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 Encephalitis in the United States

Eastern Equine Encephalitis

Virus Family

Togaviridae (genus Alphavirus)

U.S. Geographic Areas

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

Symptom Onset

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

Incidence and Mortality Rates

About 5 to 10 cases are reported each year. About a third of people who contract EEE die from it and survivors usually have significant mental and physical impairment.

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 to 10 days following infection.

Incidence and Mortality Rates

Very rare. Low mortality rate but many survivors have complications afterward. Most severe in children, especially those younger than 1 year. Infants may develop 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 primarily occurs in central and southern states.

Symptom Onset

5 to 15 days following infection.

Incidence and Mortality Rates

About 100 cases per year on average. Mortality rate ranges between 2 to 30%, with highest rates among elderly. .

Age Risk Groups

Most people experience only mild symptoms. Older adults (over age 60) are at highest risk for severe disease, including encephalitis.

La Crosse Encephalitis

Virus Family

Bunyaviridae (genus Bunyavirus)

U.S. Geographic Areas

The most common cause of arboviral disease after West Nile virus. La Crosse encephalitis virus occurs most frequently in upper Midwestern, southeastern, and mid-Atlantic states. Most cases have occurred in Ohio, West Virginia, and Wisconsin.

Unlike other encephalitis viruses which originate in birds, La Crosse encephalitis is transmitted to mosquitoes from infected chipmunks and squirrels. Jamestown Canyon virus is closely related to La Crosse encephalitis virus. It has been reported in Minnesota.

Symptom Onset

5 to 15 days following infection.

Incidence and Mortality Rates

About 80 to 100 cases of LaCrosse encephalitis or neuroinvasive disease are reported each year. Mortality rates are less than 1%.

Age Risk Groups

Children younger than 16 years are most at risk for severe disease.

West Nile Encephalitis

Virus Family

Flaviviridae (genus Flavivirus).

U.S. Geographic Areas

Cases have been reported throughout the mainland United States.

Symptom Onset

3 to 14 days following infection.

Incidence and Mortality Rates

In 2013, 2,469 cases of West Nile virus (WNV) were reported to the CDC, with 114 deaths. Of all the reported cases, 51% were WNV neuroinvasive disease, which includes meningitis and encephalitis. Less than 1% of people who are infected with WNV go on to develop neurological complications. About 10% of people who develop WNV neuroinvasive disease die from this illness.

Age Risk Groups

Adults over age 50.

West Nile Virus (WNV): 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 2013, states with the highest number of reported cases included California, Colorado, Nebraska, and Texas.

The year 2012 was a record one for West Nile virus, with the largest number of cases in nearly a decade. That summer, Dallas, Texas experienced an epidemic of WNV encephalitis. An unusually warm and wet winter, combined with dense housing patterns, created ideal mosquito breeding conditions, allowing the virus to spread.

How WNV Is Transmitted: 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. It can be deadly to some types of birds such as crows and jays.

During the season when mosquitoes are prevalent, a sampling of dead birds is analyzed to determine if they died of WNV. This sampling technique is used to predict a potential outbreak of WNV in humans.

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 all donated blood and organs.) There have also been very rare 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, which includes encephalitis and meningitis. WNV neuroinvasive disease is fatal in about 10% of cases. Survivors often experience lingering physical and mental neurological effects, which are sometimes permanent.

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.

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 Powassan virus, was reported in 2009. Cases of tick-borne encephalitis have also been reported in association Rocky Mountain spotted fever, but this is a bacterial (rickettsial), not viral, infection.

Other Viral Causes of Encephalitis

Rabies: The rabies virus is transmitted from the saliva of an infected animal. The encephalitis it causes is virtually always fatal but although it is more common in Eastern Europe, it is very rare in the U.S. Only 1 or 2 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, can cause encephalitis as well. The risk is greatest for people who have weakened immune systems.

Enteroviruses: Enteroviruses consist of a large group of viruses (including coxsackieviruses) that enter the body through the gastrointestinal tract and are often responsible for a "stomach virus." Although they account for only a small percentage of viral encephalitis cases, one particular enterovirus (D68) has recently been linked to cases of encephalitis and paralysis. This link is still being investigated. Polio, a disease that has been virtually eliminated in North America thru the widespread use of vaccines, is caused by a member of the Enterovirus family.

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.


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 adults are at higher risk for Eastern equine, St. Louis, and West Nile virus encephalitis.

Medical Conditions

People whose immune systems are compromised by conditions such as HIV-AIDS, cancer therapies, or organ transplantation are not especially more susceptible than other individuals to any form of encephalitis but they are more prone to develop a more severe case and more long term damage.

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

Risk Factors for Arboviruses

Geography: The primary risk factor for arbovirus encephalitis is living or working in areas of possible exposure to virus-carrying mosquitoes. People who work outdoors or spend time in outdoor recreational activities are particularly at risk.

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 occurs in only a small percentage of West Nile infections

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.


Mild Encephalitis

Mild cases of encephalitis generally present with fatigue, weakness, possibly low grade fever, and headache. Most people who have mild cases of encephalitis make a full recovery within 2 to 4 weeks, although many will continue to feel fatigued and "out of sorts" for many weeks thereafter.

Severe Encephalitis

Prognosis for severe encephalitis depends on many factors, including:

  • Age: worse outcomes for infants under age 12 months and adults over age 55
  • Immune status: worse outcomes for people with weakened immune systems
  • Preexisting neurological conditions: worse outcomes for people who have a history of other neurological disorders (Parkinson disease, stroke)
  • Virulence of the virus: the severity of the disease the virus causes

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 severe 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) to diffuse (throughout the brain).

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)

While coma can occur in people with severe encephalitis, it does not necessarily predict a fatal or severe outcome. Some people experience only mild-to-moderate complications after awakening from an encephalitis-associated coma.


Symptoms of encephalitis usually appear within several days to weeks of exposure to the virus. Some people have no or very mild symptoms. In other cases, symptoms may be severe or life-threatening.

In milder cases, symptoms may include:

  • Mild headache
  • Low-grade fever
  • Achy muscles and joints
  • Loss of appetite
  • Fatigue
  • Nausea and vomiting.

Severe symptoms that require immediate medical attention include:

  • High fever
  • Severe headache
  • Stiff neck and back
  • Sensitivity to light (photophobia)
  • Confusion
  • Drowsiness and difficulty staying awake
  • Speech, hearing, and vision problems
  • Muscle weakness
  • Partial paralysis
  • Seizures
  • Sudden dementia
  • Loss of consciousness
  • Coma

Symptoms in Infants: Infants with herpes virus encephalitis may develop lesions in the mouth, in the eye, or on the skin 1 to 45 days after birth. Other symptoms in infants may include fever, lethargy, poor feeding, irritability, crying more than usual, vomiting, and body stiffness. The fontanels, the soft spots on their head where the skull has not yet closed, may bulge outward.


The various types of encephalitis produce similar symptoms so doctors cannot rely strictly on clinical features to differentiate among the many viral causes. The primary objective in diagnosing viral encephalitis is to determine if it is caused by:
  • Herpes simplex or other herpes viruses, which can be treated with acyclovir
  • Arboviruses or other viruses that can be managed only by targeting symptoms

Encephalitis needs to be treated right away and time is of the essence. Even though acyclovir is only effective for herpes encephalitis (not encephalitis caused by West Nile virus or other viruses) health care providers will start immediate treatment with this drug.

The results of diagnostic tests, which may take several days to complete, can help determine whether or not acyclovir should be continued, or if the focus should be on symptom management alone.

Imaging Techniques

If encephalitis is suspected, imaging tests are 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 suggestive of herpes simplex encephalitis.

Cerebrospinal Fluid Tests

When encephalitis is suspected, a sample of cerebrospinal fluid (CSF) is taken using lumbar puncture (spinal tap). This procedure involves inserting a needle between two vertebrae in the lower back. The CSF pressure is measured and a fluid sample is collected. The sample is sent to a lab to evaluate white blood cell count and check for signs of infection or inflammation.

Cerebrospinal fluid is used to test for herpes viruses, as well as other viruses, and to look for the presence of the West Nile virus itself or antibodies to other virus types. While a cerebrospinal fluid test is necessary to diagnose encephalitis and to determine which virus is causing the infection, it 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. Such blood tests may determine whether a particular virus infection is present but, by themselves, cannot distinguish between viral infection of the brain and viral infection at other sites in the body.

Brain Biopsy

If necessary, tiny samples of brain tissue can be surgically removed for examination and testing for the presence of the virus. Brain biopsy is uncommonly performed but may be warranted in cases of severe or worsening encephalitis where the diagnosis remains in doubt even after all the above tests.


Most treatments for encephalitis focus on supportive care (rest, nutrition, and fluids) to help the body fight the infection and relieve inflammation. Antiviral drugs can only treat herpes simplex encephalitis (and more rare types of herpes encephalitis). There are no antiviral drugs to specifically treat the other viral forms of encephalitis.

People 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 appropriate treatments. It is very important to lower fever and ease the pressure caused by swelling of the brain.

Antiviral Drug Treatment

Although it is difficult to quickly diagnose the cause of encephalitis, rapid treatment is essential. Clinical guidelines recommend immediately administering intravenously the antiviral drug acyclovir without waiting to confirm if herpes simplex is the cause. 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.

  • Anticonvulsant drug may be given orally or intravenously to prevent seizures.
  • 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, as well as 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 viral infections are being investigated.

Post-Treatment Care

Severe encephalitis can cause neurological impairments. Physical therapy, speech therapy, and occupational therapy may be helpful. Even those with "mild" encephalitis should be aware that they can feel fatigued and unwell for weeks or even months after the infection has resolved.


Certain vaccines can help prevent the diseases that can lead to encephalitis.

Vaccines for Measles, Mumps, Rubella, and Varicella-Zoster Viruses

Measles Virus: Measles used to be a very common cause of viral encephalitis. Fortunately, vaccination programs have nearly eliminated this dreaded disease. (Unfortunately, there has been an increase in cases in recent years due to parents opposing childhood vaccines.) Children now receive immunization against measles as part of a combined vaccine for measles, mumps, and rubella.

Varicella-Zoster Virus: The varicella-zoster virus (VZV) is a type of herpes virus that causes both chickenpox (varicella) and shingles (herpes zoster). Chickenpox occurs from first-time exposure to the virus and usually affects children. Shingles is a later reactivation of the virus that typically strikes adults. Uncommonly, the varicella-zoster virus can cause encephalitis. Children are vaccinated against chickenpox as part of their regular immunization schedule. A vaccine for shingles (Zostavax) is available for adults age 50 years and older.

Vaccines for Arboviruses

A vaccine (Ixiaro) is available for children and adults traveling to regions where Japanese encephalitis is endemic. Countries with high rates of Japanese encephalitis include Vietnam, Cambodia, Myanmar (Burma), India, Pakistan, Nepal, Malaysia, Korea, northern Thailand, Malaysia, Sri Lanka, and the Philippines.

Another type of vaccine is used to prevent tick-borne encephalitis (TBE) in travelers visiting regions where this type of encephalitis is prevalent. TBE is found mainly in Eastern and Central Europe. Two types of these vaccines (FSME-IMMUN and Encepur) are available in Canada and many European countries, but they are not approved or available in the United States.

Scientists are investigating several types of experimental vaccines for West Nile virus, but this research is still in its early stages.

Rabies Vaccine and Immune Globuli

There are two types of rabies vaccines: pre-exposure and post-exposure. The pre-exposure vaccine is for people who face occupational risks for rabies or who will be traveling to countries where rabies is endemic. The post-exposure vaccine is for anyone bitten by an animal suspected of having rabies.

People who never received pre-exposure vaccination may also receive a shot of immune globulin unless they were previously vaccinated. The regimen is 1 shot of immune globulin and 4 shots of post-exposure rabies vaccine given over a period of 2 weeks.

The current 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. Pain at the injection site and low-grade fever may follow the immune globulin shot.


Polio has been virtually eliminated from North America and the rest of the world through the use of polio vaccine, although rare cases continue to be found in areas of social disruption such as the Middle East and some parts of Africa.

Two types of vaccines are available: an attenuated oral preparation where the virus has been weakened and modified so that it can protect but not cause disease, and a killed virus vaccine where the virus has been destroyed (by heating) but is still able to produce an immune response.

The attenuated vaccine is the preferable material, although the heat-killed vaccine is occasionally used in people who have a weakened immune systems.


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 encephalitis. The most complete personal protection program is to apply the insect repellant DEET to the skin and permethrin to clothing.

DEET and Other Insect Repellants for Skin

DEET: Most insect repellents contain the chemical DEET, which remains the gold standard for mosquito and tick repellents. Concentrations in repellant products range from 10 to 98%. The concentration level determines the duration of protection: a 30% concentration supplies protection for 5 hours.) DEET is approved for both adults and children, but it should not be used on infants younger than 2 months.

When applying DEET or other insect repellant products:

  • Do not apply directly to the face. Apply first to your hands, and then your face..
  • Do not apply over any cuts, wounds, or irritated skin.
  • Do not apply to skin covered by clothing.
  • Do not apply to the hands or near the eyes or mouth of young children. Adults should apply repellent to children; do not let children apply it themselves.
  • Thoroughly wash any treated skin after going back inside. (DEET can result in serious side effects if excessive amounts remain in prolonged contact with the skin.)
  • DEET can be applied to clothes but be aware that it can damage some synthetic fabrics.

Other Insect Repellent Products: The CDC also recommends the mosquito repellents picaridin and oil of lemon eucalyptus.

Picaridin is an alternative to DEET. Some of the advantages of picaridin are that it is odorless and does not stain or damage fabrics. Picaridin is available in concentrations ranging from 5 to 20%. Stronger concentrations can last up to 8 hours. Picaridin is safe for adults and children but, like all insect repellants, should not be applied on children younger than 2 months..

Oil of lemon eucalyptus is a chemically synthesized version of an extract found in lemon eucalyptus trees. In comparative 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 due to risks for skin irritation.

Permethrin for Clothing

Permethrin is an insect repellent used to treat clothing and bed nets, not for skin. Items sprayed or soaked in permethrin remain protective against mosquitoes and ticks for 5 to 6 washes. Allow clothing to air dry for several hours before using it. You can also buy clothing commercially pre-treated with permethrin, which can last for up to 70 washes.

Controlling Mosquitoes around the House

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

  • Look for any source of standing water, where mosquitoes can breed. 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 to 4 days.
  • Swimming pools and hot tubs should be clean and chlorinated or drained and covered if not in use.
  • Cut weeds and mow grass regularly. Clean vegetation and debris from the edges of ponds.
  • Keep gutters clean and unclogged.
  • Use products such as Mosquito Dunk, which are are pesticides that kill mosquito larvae before they can hatch. They are applied on a monthly basis to standing water (in bird baths, flower pots, and rain gutters) during mosquito season. They are safe for people, pets, and wildlife.

Mosquito Traps and Bug Zappers: 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, are not effective for mosquito control. An additional concern is that they can kill beneficial insects.

Citronella Candles: Burning citronella candles can modestly reduce 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 can reduce mosquito infiltration. Where air-conditioning is not available, fans may be helpful. Mosquitoes do not like to fly in windy air.
  • Do not wear perfumes.
  • Wash your hair several times a week.

Community Mosquito Control Programs

Spraying: 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. Although it is unlikely that you can contract West Nile virus from a dead bird, you should never touch a dead animal with your bare hands.


  • www.cdc.gov -- The U.S. Centers for Disease Control (CDC)
  • www.cdc.gov/ncezid/dvbd/-- CDC website for arboviruses
  • www.cdc.gov/westnile -- CDC West Nile virus website
  • www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke
  • www.niaid.nih.gov -- National Institute of Allergy and Infectious Diseases
  • www.epa.gov/mosquitocontrol -- U.S. Environmental Protection Agency (EPA) Mosquito Control


Aksamit AJ Jr. Acute viral encephalitis. In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier Saunders; 2011:2376-2379.

Armstrong PM, Andreadis TG. Eastern equine encephalitis virus--old enemy, new threat. N Engl J Med. 2013;368(18):1670-1673.

Beckham JD, Tyler KL. Encephalitis. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Disease. 7th ed. Churchil Livingstone Elsevier; 2009:1243-1263.

Bleck TP. Arthropod-borne viruses affecting the central nervous system. In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier Saunders; 2011:2161-2168.

Centers for Disease Control and Prevention (CDC). Use of Japanese encephalitis vaccine in children: recommendations of the advisory committee on immunization practices, 2013. MMWR Morb Mortal Wkly Rep. 2013 Nov 15;62(45):898-900.

Chung WM, Buseman CM, Joyner SN, et al. The 2012 West Nile encephalitis epidemic in Dallas, Texas. JAMA. 2013;310(3):297-307.

Egdell R, Egdell D, Solomon T. Herpes simplex virus encephalitis. BMJ. 2012;344:e3630.

Fischer M, Lindsey N, Staples JE, Hills S; Centers for Disease Control and Prevention (CDC). Japanese encephalitis vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010 Mar 12;59(RR-1):1-27.

Haley RW. Controlling urban epidemics of West Nile virus infection. JAMA. 2012;308(13):1325-1326.

Lindquist L, Vapalahti O. Tick-borne encephalitis. Lancet. 2008;371(9627):1861-1871.

Lindsey NP, Hayes EB, Staples JE, Fischer M. West Nile virus disease in children, United States, 1999-2007. Pediatrics. 2009 ;123(6):e1084-e1089.

Lindsey NP, Lehman JA, Staples JE, Fischer M; Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC. West Nile virus and other arboviral diseases - United States, 2013. MMWR Morb Mortal Wkly Rep. 2014 Jun 20;63(24):521-6. PMID: 24941331 www.ncbi.nlm.nih.gov/pubmed/24941331.

Loeb M, Hanna S, Nicolle L, et al. Prognosis after West Nile virus infection. Ann Intern Med. 2008;149(4):232-241.

Petersen LR, Brault AC, Nasci RS. West Nile virus: review of the literature. JAMA. 2013;310(3):308-315.

Petersen LR, Fischer M. Unpredictable and difficult to control--the adolescence of West Nile virus. N Engl J Med. 2012;367(14):1281-1284.

Tavakoli NP, Wang H, Dupuis M, et al. Fatal case of deer tick virus encephalitis. N Engl J Med. 2009;360(20):2099-2107.

Tunkel AR, Glaser CA, Bloch KC, et al. The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2008;47(3):303-327.

Tyler KL. Emerging viral infections of the central nervous system: part 1. Arch Neurol. 2009;66(8):939-948.

Whitley RJ. Herpes simplex virus infections. In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier Saunders; 2011:2125-2128.

To Top