1. KOREAN HEMORRHAGIC FEVER An Ever Present Danger to U.S. Forces Korea COL (Ret) Terry A. Klein, PhD Regional Emerging Infectious Disease Consultant Force Health Protection, 18 th Medical Command 13 February 2007

2. Collaborators Dr. Jin-Won Song, Korea University Dr. Luck-Ju Baek, Korea University Dr. Heung-Chul Kim, 5 th MED DET LTC William Sames, 18 th MEDCOM LTC Douglas Burkett, Air Force LTC Monica O’Guinn, USAMRIID MAJ John Lee, USAMRIID MAJ Anthony Schuster, CHPPM Commanders and Personnel, MED DETS

3. Rodent-borne Disease Surveillance  Purpose: Reduce the impact of rodent-borne diseases  Background: >400 cases of HFRS annually  Problem: Rodent-borne diseases often “epidemic”.  Benefits: Increase “early warning” potential  Surveillance: HFRS, murine typhus, scrub typhus, and leptospirosis  Environmental modifications: Affects population and disease potential of emerging infectious diseases

4. Hantaviruses are worldwide HFRS (KHF) is a viral disease Maintained by rodent reservoirs Ranges in severity from mild to fatal Prevention is the best measure If prevention fails, requires rapid treatment/supportive care (ribovirin) Risks related to occupation and behavior No US approved vaccine Introduction

5. Respiratory via aerosolized rodent secreta/excreta (3 - 8% mortality) No horizontal human to human transmission 2,422 US cases during Korean war Prevention requires good field sanitation Early supportive treatment required HFRS Transmission

6. Number of Korean Hemorrhagic Fever Cases in ROK Personnel, 1986 - 2006

7. Number of Reported Cases Number of HFRS Cases in USFK Personnel*, 1986 – 2005 Year * USFK includes US soldiers and KATUSAs; # One case during 2001 due to Seoul virus contracted at Yongsan Garrison #

8. HFRS Patients by Area, 2005 KHF Patients by Area, ROK Military

9. Figure 1. Apodemus agrarius, the primary reservoir of Hantaan virus Rattus norvegicus Apodemus peninsulae Figure 3. A. peninsulae, primary reservoir of Soochong virus Figure 2. Rattus norvegicus, the primary reservoir of Seoul virus Apodemus agrarius Rodents & Hantaviruses of Korea

10. Rodent-borne disease surveillance at selected US military training sites near the DMZ, 2000 - 2006 North Korea South Korea 1 2 1 2 1 1 HFRS Risk High Risk Moderate Risk Low Risk HFRS Cases 2 1

11. (A) Overview of training site. (B) Rice paddies associated with tall grasses bordering training area. (C) Road leading through a “tank trap” to the main training area (A). (D). Tall grassy intermittent stream bed. A C B D Rodent-borne disease surveillance at Dagmar North Training Area

12. Changing Seasons, FP-60 Early Fall Spring Early Summer Winter Early Fall

13. Habitat Modification, FP-60

14. Number of Small Mammals Captured Near the DMZ, 2001 – 2005

15. Patient # 1 # 2 # 3 # 4 Onset of 5 Oct 3 Nov 6 Nov 12 Nov Symptoms Training 20-29 Sep 8-21 Oct 8-15 Oct 8-21 Oct Dates Training LTA 320, 36, 37 Twin Bridges Twin Bridges Twin Bridges Sites FP 60 Rodriguez Rodriguez Watkins Watkins Incubation 27 – 36 Days 26 – 39 Days 29 – 35 Days 35 – 48 Days Period Virus FP 60 Twin Bridges Twin Bridges Twin Bridges Match South North South Table 1. Summary of patient histories for four patients that acquired HFRS infections while training at US and ROK operated military training sites near the DMZ.

16. Figure 10. NJ Tree based on 281-bps nucleotides of the G2-M segment of the HTNV from USFK HFRS Patients 1-4, 2005. FP60 FP10 TBTA-N TBTA-S

17. Firing Point 60, Rodent Habitat/Activities

18. Primary Rodent Trapping Lines

19. Patients # 2-05 and # 4-05 Patient # 3-05

20. Twin Bridges TA – Rodent Habitat Potential Infected Dust Rodent Foraging and Migration Fighting Position Dirt Road Adjacent to Fighting Positions Virus Laden Rodent Feces

21. Training Site Dirt Road Rodent Activity Twin Bridges TA – Rodent Habitat

23. Fig. 12. Dust created by wheeled vehicles along a dirt road and tracked vehicles at barren training site associated with tall grass habitats. Fig. 13. Wetting down dirt roads to reduce dust. Fig. 14. Discarding of refuse adjacent to primary rodent habitat (tall grasses).

25. Dagmar North