1. Hantavirus: Could it occur in the United States? Danny L. Self (Ph.D.) Walden University PUBH 8165-3 Dr. Lezah Brown-Ellington Winter 2012-2013 Danny L. Self (Ph.D.) Walden University PUBH 8165-3 Dr. Lezah Brown-Ellington Winter 2012-2013

2. Hantavirus Old World Hantavirus New World Hantavirus

3. (Centers for Disease Control and Prevention, 2012)

4. Host of the Hantavirus Rodents –Deer mouse –Cotton rat –Rice rat –White-footed mouse

5. Deer mouse (Peromyscus maniculatus) (Centers for Disease Control and Prevention, 2012)

6. Cotton rat (Sigmodon hispidus)

7. Rice rat (Oryzomys palustris)

8. White-footed mouse (Peromyscus leucopus)

9. Hemorrhagic Fever with Renal Syndrome (HFRS) Korean hemorrhagic fever Epidemic hemorrhagic fever Nephropathis epidemica Hantaan virus Dobrava virus Saaremaa virus Seoul virus Puumala virus

10. Hantavirus Pulmonary Syndrome (HPS) Infectious disease caused by the Hantavirus –Flu-like symptoms Occur irregularly in rural areas Numerous types –Sin Nombre hantavirus –Carried by rodents Treatment limited

11. Characteristics of some known Hantaviruses HantavirusesGeographic Region ReservoirPathologyMortality HantaanAsiaField mouseRenal5-15% SeoulWorldwideDomestic ratRenal1% PuumalaNorthern Europe Bank voleRenal1% Prospect HillUnited States Meadow voleNo known human disease N/A Sin HombreNorth America Deer mousePulmonary50% (Centers for Disease Control and Prevention, 2012)

12. Comparison of HFRS & HPS FeatureHFRSHPS Major target organKidneyLung First phaseFebrileFebrile “prodrome” Second phaseShockShock, pulmonary edema EvolutionOliguria, diuresis, convalescence Diuresis, convalescence Mortality1-15%50% (Centers for Disease Control and Prevention, 2012)

13. Clinical Case Definition A febrile illness (body temperature of 101° F or greater) characterized by bilateral diffuse interstitial edema that may radiographically resemble ARDS, with respiratory compromise which requires supplemental oxygen, which develops within 72 hours of hospitalization, and occurring in a previously healthy person Unexplained respiratory illness resulting in death, with an autopsy examination demonstrating noncardiogenic pulmonary edema without an identifiable cause

14. Laboratory Criteria for Diagnosis Detection of hantavirus-specific immunoglobulin M or rising titers of hantavirus-specific immunoglobulin G Detection of hantavirus-specific ribonucleic acid sequence by polymerase chain reaction in clinical specimens Detection of hantavirus antigen by immunohistochemistry

15. Incidence Human to human transmission does not exist U.S. national parks One’s own home

16. Potential risk activities for HPS Opening and cleaning previously unused buildings Housecleaning activities Work-related exposure Campers Hikers

17. Ecology Enzootic CycleEpizootic Cycle (Centers for Disease Control and Prevention, 2012)

18. Transmission of the Hantavirus (Arizona Geographic Alliance, 2001)

19. Symptoms Early Symptoms Fatigue Fever Muscle aches Headaches Dizziness Chills Abdominal problems Late Symptoms Lungs fill with fluid Shortness of breath

20. Signs & Tests Results from physical exam Acute respiratory distress syndrome (ARDS) Kidney failure Low blood pressure (hypotension) Low blood oxygen levels Tests Blood tests to check for Hantavirus Complete blood count (CBC) Complete metabolic panel Kidney and liver function tests Chest x-ray

21. Treatment Oxygen Breath tube or machine Ribavirin

22. Complications Kidney failure Heart failure Lung failure

23. Expectations(Prognosis) Advances rapidly If lungs are infected death will follow

24. Mortality 50%

25. Prevention Avoid exposure to rodent urine or droppings

26. Incidences in the United States 1993 –Four Corners –Appalachian Trail 2012 –Yosemite National Park

27. (Centers for Disease Control and Prevention, 2012)

28. Annual U.S. HPS Cases & Case-fatality (1993-2011) (Centers for Disease Control and Prevention, 2012)

29. Yosemite National Park September 2012 –10 confirmed cases –3 deaths

30. September 6, 2012: Case Count (State of Residence) Map (Centers for Disease Control and Prevention, 2012)

31. September 13, 2012: Case Count (State of Residence) Map (Centers for Disease Control and Prevention, 2012)

32. Current Case Count (State of Residence) Map (Centers for Disease Control and Prevention, 2012)

33. Incidences Outside the United States HFRS –150,000 – 200,000 cases HPS –200 cases

34. Geographical representation of approximate Hantaviral disease incidence by country per year. Jonsson C B et al. Clin. Microbiol. Rev. 2010;23:412-441

35. Questions?

36. References Arizona Geographic Alliance. (2001). Hantavirus Student Guide: Arizona Geographic Alliance. Retrieved from Arizona Geographic Alliance: http://alliance.la.asu.edu/model/geoliteracyCD/LessonFiles/DornVaagen/DornHantaS.pdf Bi, Z., Formenty, P. B., & Roth, C. E. (2007). Hantavirus Infection: A Review and Global Update. J Infect Developing Countries 2008, 3-23. Ceneters for Disease Control and Prevention. (1994, December 4). MMWR - Emerging Infectious Diseases Hantavirus Puolmonary Syndrome --Virginia, 1993: Ceneters for Disease Control and Prevention. Retrieved from Ceneters for Disease Control and Prevention: http://www.cdc.gov/mmwr/preview/mmwrhtml/00033796.htm Centers for Disease Control and Prevention. (2011, May 17). Hantavirus: Hemorrhagic Fever with Renal Syndrome (HFRS): Centers for Disease Control and Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/hantavirus/hfrs/index.html Centers for Disease Control and Prevention. (2012, August 29). Rodents in the United States that caryy Hantavirus: Centers for Disease Control and Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/hantavirus/rodents/index.html Centers for Disease Control and Prevention. (2012, August 29). Deer mouse habitat in North America: Centers for Disease Control and Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/hantavirus/rodents/deer-mouse.html

37. References Centers for Disease Control and Prevention. (2012, August 29). Ecology - Hantavirus: Centers for Disease Control and Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/hantavirus/technical/hanta/ecology.html Centers for Disease Control and Prevention. (2012, December 26). Hantavirus - Surveillance: Centers for Disease Control and Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/hantavirus/surveillance/state-of-exposure.html Centers for Disease Control and Prevention. (2012, August 29). Hantavirus Pulmonary Syndrome (HPS) Case Definition: Centers for Disease Control and Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/hantavirus/health-care-workers/hps-case- definition.html Centers for Disease Control and Prevention. (2012, August 29). Hantavirus: Virology: Centers for Disease Control and Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/hantavirus/technical/hanta/virology.html Centers for Disease Control and Prevention. (2012, August 29). How people get Hantavirus Pulmonary Syndrome: Centers for Disease Control and Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/hantavirus/hps/transmission.html

38. References Centers for Disease Control and Prevention. (2012, September 17). Outbreak of Hantavirus Infection in Yosemite National Park: Centers for DiseaseControl and Prevention. Retrieved from Centers for DiseaseControl and Prevention: http://www.cdc.gov/hantavirus/outbreaks/yosemite-national-park- 2012.html Centers for Disease Control and Prevention. (2012, August 29). Signs & Symptoms for Hantavirus Pulmonary Syndrome: Centers for Disease Control and Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/hantavirus/hps/symptoms.html Jonsson, C. B., Figueiredo, L. T., & Vapalahti, O. (2010). A Global Perspective on Hantavirus Ecology, Epidemiology, and Disease. American Society of Microbiology, 415-441. Mayo Clinic Staff. (2011, February 11). Hantavirus Pulmonary Syndrom: Mayo Clinic. Retrieved from Mayo Clinic: http://www.mayoclinic.com/health/hantavirus-pulmonary-syndrome/DS00900 PubMed Health. (2011, March 11). Hantavirus: PubMed Health. Retrieved from PubMed Health: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002358/ The Free Dictionary. (2013). Medical-dictionary: The Free Dictionary. Retrieved from The Free Dictionary: http://medical-dictionary.thefreedictionary.com