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JL Alexander, TDSHS, Zoonosis Control Division

TWO CLUSTERS OF HANTAVIRUS INFECTION IN TEXAS Diseases in Nature Transmissible to Man June 12, 2007. JL Alexander, TDSHS, Zoonosis Control Division MN Rivers, Texas Tech University Health Sciences Center, Amarillo RE Rohde, Clinical Laboratory Science, Texas State University

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JL Alexander, TDSHS, Zoonosis Control Division

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  1. TWO CLUSTERS OF HANTAVIRUS INFECTION IN TEXASDiseases in Nature Transmissible to ManJune 12, 2007 JL Alexander, TDSHS, Zoonosis Control Division MN Rivers, Texas Tech University Health Sciences Center, Amarillo RE Rohde, Clinical Laboratory Science, Texas State University JR Pierce Jr, Amarillo Bi-City-County Health District & Texas Tech University Health Sciences Center, Amarillo

  2. Outline • General review of hantavirus • Report of two clusters in Texas • Review of Texas data • Implications of this report

  3. Transmission of Hantaviruses Chronically infected rodent Horizontal transmission of infection by intraspecific aggressive behavior Virus also present in throat swab and feces Virus is present in aerosolized excreta, particularly urine Secondary aerosols, mucous membrane contact, and skin breaches are also sources of infection

  4. Peromyscus maniculatus Deer mouse Sigmodon hispidus Cotton rat

  5. Hantaviruses in the New World Subfamily Sigmodontinae associated viruses VirusHostLocation Sin nombre Peromyscus maniculatus West & Central U.S. & Canada Monongahela Peromyscus maniculatus Eastern U.S. & Canada New York Peromyscus leucopus Eastern U.S. Bayou Oryzomys palustris Southeastern U.S. Black Creek Canal Sigmodon hispidus Florida Numerous other hantaviruses have been identified but not linked to human disease

  6. Hantaviruses in the New World Subfamily Sigmodontinae associated viruses VirusHostLocation Andes Oligoryzomys longicaudatus Argentina & Chile Oran Oligorozomys longicaudatus Northwest Argentina Lechiguanas Oligoryzomys flavescens Central Argentina Hu39694 Unknown Central Argentina Laguna Negra Calomys laucha Paraguay & Bolivia Bermejo Oligoryzomys chacoensis Northwest Argentina Juquitiba Unknown Brazil Choclo Oligoryzomys fulvescens Panama Numerous other hantaviruses have been identified but not linked to human disease

  7. HPS - Clinical Presentation

  8. =No. of cases 88 Number of Casesof Hantavirus Pulmonary Syndrome (HPS) (Region of the Americas, 1993–2004*) Canada 362 USA Panama 35 Brazil 321 Bolivia 36 Paraguay Chile 331 99 48 Total cases = 1910 592 Uruguay Argentina * 2004 using preliminary data.

  9. 0 Cases 1-4 Cases 5-9 Cases >=10 Cases Hantavirus Pulmonary Syndrome Cases by Reporting State United States – March 26, 2007 Total Cases (N=465 in 31 States)

  10. Hantavirus Pulmonary Syndrome, United States Descriptive Demographic Statistics March 26, 2007 465 (100%) N Male 292 (64%) 173 (37%) Female 355 (78%) White American Indian 87 (19%) 7 ( 2%) Black Asian 3 ( 1%) Hispanic 65 (14%) Dead 165 (35%) Age (years) Mean=38 [1 - 83]

  11. Hantavirus in North America • Usually sporadic, few clusters reported • CDC review (Emerg Inf Dis 1997;3:361) in 1997 of 160 cases determined that few (7%) occurred in clusters • As opposed to South American hantaviruses, no human-to-human transmission has been described in North America • Sin nombre most common type • Typically HPS but may have infection without pneumonia

  12. Cluster #1 – Randall county 07/03 • 50 year old plumber’s assistant previously healthy. Smokes. Daily alcohol consumption. • Seen in ED with four days of chills, myalgias, vomiting, cough, and shortness of breath. Thought to have cold and sent home on symptomatic treatment

  13. Cluster #1 – contd • Returns to ED two days later with worsening shortness of breath • WBC=9100 (73% segs, 12% bands); H/H=17.5/52.3; plts=92,000. CXR=RML/RLL interstitial infiltrates • Rapidly deteriorates and dies 48 hours later • Autopsy = diffuse bilateral pulmonary edema with sparse interstitial inflammation • Serum IgM & IgG positive for Sin Nombre virus • Epidemiologic investigation significant peridomestic exposure to mice

  14. Cluster #1 – contd • 42 year old common law wife also ill with cold, vomiting and fever. Goes to ED, signs out AMA • IgG and IgM positive for SNV • Manager of trailer park had been ill one year previously, admitted to hospital with undiagnosed bilateral pneumonia and eventually recovered. IgG positive for SNV one year later.

  15. Middle-aged daughter expired with ARD within 24 hours of admittance 4 days later Cluster #2 – Crosby county 04/02 Elderly mother expired on 4th day post-admission due to “pneumonia”

  16. Cluster #2 – contd • During mother’s illness, case’s younger brother and family from out of state had visited residence, opened a cabinet and received a “face full of dust” • Approximately two weeks later brother began exhibiting malaise, fever, myalgia; seen in ED and released • 1 week later, brother readmitted with respiratory symptoms, tested positive for SNV IgG and IgM • Recovered uneventfully

  17. Middle-aged daughter expired with ARD within 24 hours of admittance 4 days later Younger brother had visited home during the mother’s illness and became ill within 4 weeks after returning to AZ Elderly mother expired on 4th day post-admission due to “pneumonia” April/May 2002

  18. Texas HPS cases 1993 - 2006 • 32 cases SNV =26, Bayou virus = 4, Unknown = 2 • All cases were hospitalized. • BV cases were restricted to coastal counties. 19/26 (73%) of SNV cases occurred in Panhandle Plains counties. • Mortality was 40% (46% for SNV vs. 0% for BV) • Those aged 20-64 years were overrepresented (63% of cases vs. 49% of pop)

  19. High Plains Ecoregion 62.5% (20/32) of Texas HPS cases 4.7% Texas Pop

  20. Texas HPS – age and gender

  21. Texas HPS cases 1993 – 2006 (cont) • Common clinical characteristics included: • fever ≥101°F (83%) • nausea and/or vomiting (94%), diarrhea (67%), headache (86%), • hematocrit ≥55% (30%), platelets ≤100,000 (93%), creatinine ≥1.5 (60%), leukocyte count ≥20,000 (48%), bands ≥10% (85%). • 85% of HPS cases reported seeing peridomestic rodents or rodent excreta. • 85% of HPS cases were initially seen by a physician and dismissed to home, later to be admitted to the hospital

  22. Texas HPS – clinical characteristics

  23. Hantavirus Texas clusters - conclusions • We described two Texas clusters of Hantavirus infection • Both clusters involved Sin nombre virus and occurred in the Texas Panhandle. • 6 people were infected. Five developed an illness consistent with HPS; one person developed evidence of Hantavirus infection without HPS. • Overall mortality was 50% • The diagnosis was initially overlooked in 4/6 patients and was only suspected when HPS was diagnosed in an epidemiologically related case

  24. Acknowledgements • James Schuermann, BS, TDSHS Zoonosis Branch • Thomas Gerald, TTUHSC Research Associate • Fellow Investigators • Megan Rivers, TTUHSC Medical Student • Dr. James Alexander, TDSHS • Rodney Rohde, Texas State University

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