# Presentation: 574610

## Hantavirus Pulmonary Syndrome(HPS)

**Many Slides Borrowed from                                                      Special Pathogens Branch****DVRD/NCID/CDC**

**Hantavirus Pulmonary Syndrome****(HPS)**

**An overview of HPS Epidemiology and Pathology.**

**Notes:**
1.  Hantavirus pulmonary syndrome (HPS), caused by a previously unrecognized hantavirus, was first recognized in May 1993.   The disease begins with non-specific symptoms which include fever, muscle aches, headache, abdominal pain, nausea, vomiting, and progresses to include coughing and shortness of breath.  The symptoms usually occur between one and six weeks after exposure to virul ladent in rodent' excreta.  The disease rapidly progresses to cardiac and respiratory failure, usually requiring intensive care management.

## Hanta is,

**Hanta is,**
**A movie**

## A Minneapolis Punk Band

**A Minneapolis Punk Band**

## An Asian Vehicle

**An Asian Vehicle**

## A Madagascari Singer

**A Madagascari Singer**

## A book on Hanta Virus on the Navajo Reservation

**A book on Hanta Virus on the Navajo Reservation**

## Knowledge About Hanta Virus is Important...

**Knowledge About Hanta Virus is Important...**

**Knowing about Hanta Virus is almost as important as this:**

## Four Corners

**On May 14, 1993, in a rural community in the Navajo Nation near Gallup, New Mexico, an unknown microbial killer swiftly claimed the life of a young athlete. **

**                                  ****Within a week, his fiance and four others died from the disease. **

## A court Case involving Hanta and Navajo Area IHS:

**A court Case involving Hanta and Navajo Area IHS:**

## Haceesa Case

- From a Newspaper Article about the Case:
- On the evening of Saturday, April 25, 1998, twenty-five year-old Hardy Haceesa walked into a hospital emergency room complaining of a fever, difficult and painful breathing, chest discomfort, and general achiness. He told the nurse he thought his condition could be the result of exposure to mice. Haceesa was sent home that night, diagnosed with bronchitis and told to check back at the local clinic on Monday. By Tuesday evening, he was dead.
- Only after his death was Haceesa's disease diagnosed correctly: he died of hantavirus pulmonary syndrome, a rare, deadly disease caused by exposure to airborne particles of the urine of infected mice and characterized in its early stages by flu-like symptoms. Haceesa was a Navajo Indian, and the hospital where he was first seen on April 25 ­ the Northern New Mexico Navajo Hospital in Shiprock, New Mexico ­ is owned and operated by the Indian Health Service, an agency of the United States Department of Health and Human Services. As the district court observed, Shiprock Hospital stands "in the geographic center of the world for" hantavirus.

**$3.1 Million Dollars Awarded**

- So that night, the did not know that fever and aches were warning signs, and she had not been told that one of the best indications of hantavirus was a low or falling count of blood platelets, which aid in clotting. Mr. Haceesa had a platelet count of 111,000 per microliter. Less than a year earlier, his chart showed, his count had been 226,000.

## Recent local news concerning HPS.

**Recent local news concerning HPS.**

## Navajo Medical Traditions and HPS 

- In Navajo medical traditions, mice are considered to be the bearers of an ancient illness that even predates the bubonic plague in the Navajo region. Healers say that when mice enter the home, they put people at risk of infection, as people come into contact with mice droppings and urine. The illness enters through the mouth, the nose or the eyes, and it usually attacks the strongest and healthiest of the Navajo people. Therefore, traditional medicine prescribes avoiding mice, keeping them out of the hogans, and isolating food supplies.
- Some of the Navajo elders had predicted the 1993 HPS outbreak. In addition, their oral tradition says that in 1918 and 1933-34, there were similar outbreaks, after increases in rainfall produced increases in the piñon crop and the number of mice.

## Family Bunyaviridae

_**Genus **_		_**Human disease**_
*Bunyavirus**	**	*LaCrosse encephalitis, others
*Phlebovirus**	**	*Rift Valley fever, sandfly fever
*Nairovirus**	**	*Crimean-Congo hemorrhagic fever
*Tospovirus**	**	*Plant virus, no known human disease
*Hantavirus**	**	*Hemorrhagic fever with renal syndrome
*	**	**	*Hantavirus pulmonary syndrome

- 5 genera, 250 species

**Family Bunyaviridae**

**Notes:**
2.  Sin Nombre virus(formerly Muerto Canyon Virus (MCV))the most  frequent virus recognized as a cause of the Hantavirus Pulmonary Syndrome(HPS) is a member of the family Bunyaviridae.

## Characteristics of Hantaviruses

-  	No arthropod vector established
- 	Unique among genera of Bunyaviridae
-  	Rodent hosts
-   	Genus and possibly species specific
-  	Transmission
-     	Aerosolization of rodent excreta

**Characteristics of Hantaviruses**

**Notes:**
3.  Characteristics of Hantaviruses.

## Transmission of Hantaviruses

- Chronically infected rodent

- Virus is present in aerosolized excreta, particularly urine

- Horizontal transmission of infection by intraspecific aggressive behavior

- Virus also present in throat swab and feces

- Secondary aerosols, mucous membrane contact, and skin breaches are also a consideration

**Transmission of Hantaviruses**

**How often are folks exposed? = seroprevalence.**

## Seroprevalence:

- To characterize the preexistent seroprevalence of hantavirus antibodies among some persons in the area of the outbreak, serum samples collected in 1991 and 1992 as part of the Navajo Health and Nutrition Survey (CDC, unpublished data, 1991) were tested. Of samples obtained from 270 persons, antibodies to hantaviruses were present in specimens from three **(1%)** persons.

## S

**HTN Korea ***Apodemus*** ***agrarius*

**DOB Slovenia** *Apodemus flavicollis*

**SEO** **Japan** *Rattus norvegicus*

**PUU** **Finland** *Clethrionomys glareolus*

**PUU Russia** *Clethrionomys glareolus*

**PUU Sweden** *Clethrionomys glareolus*

**S**

**PUU Belgium** *Clethrionomys glareolus*

**TOP Russia** *Lemmus sibiricus*

**KBR** **Russia** *Microtus fortis*

**TUL Russia** *Microtus arvalis*

**TUL Czech** *Microtus arvalis*

**TUL Slovakia** *Microtus arvalis*

**PH** **New York** *Microtus pennsylvanicus*

**PH** **Maryland** *Microtus pennsylvanicus*

**ISLA** **California** *Microtus californicus*

**MULE** **Southern US ***Sigmodon hispidus (texensis)*

**BCC** **Florida** *Sigmodon hispidus  *

**BAY** **Southeastern US ***Oryzomys palustris*

**ANDES** **Argentina & Chile** *Oligoryzomys longicaudatus*

**LEC ** **Argentina** *Oligoryzomys flavescens *

**RIOM ** **Bolivia & Peru** *Oligoryzomys microtis*

**LN**  **Paraguay & Bolivia ***Calomys laucha*

**SN ** **New Mexico ***Peromyscus maniculatus** *

**SN** **California ***Peromyscus maniculatus *

**NY ** **New York ***Peromyscus leucopus  *

**NY ** **Rhode**** ****Island ***Peromyscus leucopus** *

**MON ** **West Virginia ***Peromyscus maniculatus**  *

**ELMC**  **Western US & Mexico ***Reithrodontomys megalotis*

**RIOS ** **Costa Rica ***Reithrodontomys  mexicanus*

**Phylogeny of Hantaviruses: Based on Sequence of S Segment**** ****(Subfamily, Hantavirus, Location, Host)**

**MURINAE**

**ARVICOLINAE**

**SIGMODONTINAE**

**Most species of rodents have a hantavirus that it shares with few other species... **

##   Subfamily Murinae associated viruses
  Virus        Host	Location                   	Disease

  Hantaan    Apodemus agrarius     	Asia, Far East Russia	HFRS
  Dobrava    Apodemus flavicollis	Balkans	HFRS	 	Apodemus agrarius	Europe		         
  Seoul	  Rattus norvegicus	Worldwide	HFRS 	  Rattus rattus	

  Subfamily Arvicolinae associated viruses
  Virus        Host 	Location                 	Disease

  Puumala    	Clethrionomys glareolus Europe	HFRS

    *Numerous other hantaviruses have been identified but not linked to human disease

**  **_**Virus**_**        **_**Host**_**	**_**Location**_**                   ****	**_**Disease**_
-   Hantaan    *Apodemus agrarius     **	*Asia, Far East Russia	HFRS
-   Dobrava    *Apodemus flavicollis**	*Balkans	HFRS	 	*Apodemus agrarius**	*Europe
-   Seoul	  *Rattus norvegicus**	*Worldwide	HFRS 	  *Rattus rattus*
**  ****Subfamily Arvicolinae associated viruses**
**  **_**Virus**_**        **_**Host **_**	**_**Location **_**                ****	**_**Disease**_
-   Puumala    	*Clethrionomys glareolus* Europe	HFRS
-     *Numerous other hantaviruses have been identified but not linked to human disease

**Hantaviruses in the Old World**

**Hanta Virus is in Eurasia**

## 
  Subfamily Sigmodontinae associated viruses

	Virus                  	 Host			Location       	  Disease
	Sin Nombre		 Peromyscus maniculatus 	West & Central  		 	HPS
  						U.S. & Canada
   Monongahela    		 Peromyscus maniculatus 	Eastern U.S. &  		 	HPS
						Canada           
   New York		 Peromyscus leucopus  			Eastern U.S.  			 	HPS
	Bayou		 Oryzomys palustris 			Southeastern U.S. 	HPS
	Black Creek Canal Sigmodon hispidus			Florida     							HPS

   * Numerous other hantaviruses have been identified but not linked to human disease

**  ****Subfamily Sigmodontinae associated viruses**
**	**_**Virus**_**                  ****	**** **_**Host**_**	****	****	**_**Location**_**       ****	****  **_**Disease**_
- 	Sin Nombre		 *Peromyscus maniculatus* 	West & Central  		 	HPS
-   						U.S. & Canada
-    Monongahela    		 *Peromyscus maniculatus* 	Eastern U.S. &  		 	HPS
- 						Canada
-    New York		 *Peromyscus leucopus*  			Eastern U.S.  			 	HPS
- 	Bayou		 *Oryzomys palustris* 			Southeastern U.S. 	HPS
- 	Black Creek Canal *Sigmodon hispidus**	**	**	*Florida     							HPS
-    * Numerous other hantaviruses have been identified but not linked to human disease

**Hantaviruses in the New World (1)**

**...****North America**

##    Subfamily Sigmodontinae associated viruses (cont.)
	 Virus           	Host	    Location    	 Disease
	 Andes		Oligoryzomys longicaudatus		Argentina &				HPS						Chile
	 Oran		Oligorozomys longicaudatus Northwestern				HPS						Argentina	
	 Lechiguanas	Oligoryzomys flavescens			Central Argentina	HPS
	 Hu39694		Unknown			Central Argentina	HPS
	 Laguna Negra	Calomys laucha			Paraguay &				HPS						Bolivia	
	 Juquitiba		Unknown			Brazil				HPS

   * Numerous other hantaviruses have been identified but not linked to human disease

**	**** **_**Virus**_**           ****	**_**Host**_**	****    **_**Location**_**    ****	**** **_**Disease**_
- 	 Andes		*Oligoryzomys longicaudatus**	**	*Argentina &				HPS						Chile
- 	 Oran		*Oligorozomys longicaudatus* Northwestern				HPS						Argentina
- 	 Lechiguanas	*Oligoryzomys flavescens**	**	**	*Central Argentina	HPS
- 	 Hu39694		Unknown			Central Argentina	HPS
- 	 Laguna Negra	*Calomys laucha**	**	**	*Paraguay &				HPS						Bolivia
- 	 Juquitiba		Unknown			Brazil				HPS
-    * Numerous other hantaviruses have been identified but not linked to human disease

**Hantaviruses in the New World** (2)

** ****and South America**

## Sin Nombre

**Sin Nombre**
*Peromyscus maniculatus*

**Rio Segundo**
*Reithrodontomys mexicanus*

**El Moro Canyon**
*Reithrodontomys megalotis*

**Andes**
*Oligoryzomys longicaudatus*

**Bayou**
*Oryzomys palustris*

**Black Creek Canal**
*Sigmodon hispidus*

**Rio Mamore**
*Oligoryzomys microtis*

**Laguna Negra**
*Calomys laucha*

**Muleshoe**
*Sigmodon hispidus*

**New York**
*Peromyscus leucopus*

**Juquitiba**
- Unknown Host

**Or****án**
*Oligoryzomys longicaudatus*

**C****añ****o Delgadito**
*Sigmodon alstoni*

**Isla Vista**
*Microtus californicus*

**Bloodland Lake**
*Microtus ochrogaster*

**Prospect Hill**
*Microtus pennsylvanicus*

**Bermejo**
*Oligoryzomys chacoensis*

## Hantavirus Pulmonary Syndrome Cases by OutcomeUnited States, as of February 1, 2006

- 2006    C Schmitt MD

- Hantavirus Pulmonary Syndrome Cases by OutcomeUnited States, as of February 1, 2006

- *Thirty-two additional cases (nineteen deceased) with onset before 1993 not shown.

**      ****1993        1994       1995       1996       1997       1998        1999        2000       2001       2002        2003       2004**

**N=416***

**Initial 4-Corners Outbreak**

## Hantavirus Pulmonary Syndrome Cases

**Hantavirus Pulmonary Syndrome Cases**
**by State of Exposure United States – February 1, 2006**

**Total Cases (N=416 in 30 States)**

- Twenty-five cases were reported with unknown state of exposure.

**Most of New Mexico’s Cases have been in McKinley and San Juan Counties, near us.**

## Hantavirus Pulmonary Syndrome Cases by RegionUnited States, as of February 1, 2006

**Hantavirus Pulmonary Syndrome Cases by Region****United States, as of February 1, 2006**

- * Eleven Four Corners and twenty-one Non-Four Corners cases with onset before 1993 not shown.

**N=416***

**      ****1993        1994       1995       1996       1997        1998       1999        2000       2001       2002        2003        2004**

## Hantavirus Pulmonary Syndrome Cases by RegionUnited States, as of February 1, 2006

**Hantavirus Pulmonary Syndrome Cases by Region****United States, as of February 1, 2006**

- * Eleven Four Corners and twenty-one Non-Four Corners cases with onset before 1993 not shown.

**N=416***

**      ****1993        1994       1995       1996       1997        1998       1999        2000       2001       2002        2003        2004**

**Cases in the 4-corners Cluster because the large changes in the mouse population/carriage rate.**

## Why there are Clusters of Cases

- After periods of increased rain, the mouse population explodes.
- Not only are there more mice, there are more ‘mouse fights’ and other encounters increasing the percentage of mice that are carrying the Hanta Virus.  This amplifies the amount of an area’s Hanta carriage exponentially.
- When populations explode, and especially when the food supply starts to decline- mice move into houses looking for food.

## Distribution* of Peromyscus maniculatus and

**Distribution* of***** Peromyscus maniculatus *****and**
**Location of HPS Cases as of February 1, 2006**
***Total Cases (N = 416 in 30 States)***

- *Rodent distributions from:  Burt WH, Grossenheider RP.  A Field Guide to the Mammals.  3rd ed. New York, New York.  Houghton Mifflin Company. 1980

***Peromyscus***
***maniculatus***

**SNV**
**Other virus**

**Chuska and Carrizzo Mountains**

## X

**X**

**This is an aerial photograph of the Fort Defiance area.  The areas able to support a high density of mice are colored orange and red.**
**Fort Defiance is marked by the X.**
**Chinle is at the O**

**O**

## Mouse – Human Transmission

- Human case exposures/transmission of Sin Nombre virus in AZ has been linked to : Peromyscus maniculatus and P. eremicus [Deer and Cactus Mice].
- P. boylii in northern AZ has been shown to carry another Hantavirus - Limestone Canyon virus - *but nothing is known about its pathogenicity to humans*.

## Peromyscus maniculatus

- 2006    C Schmitt MD

***Peromyscus maniculatus***
**Deer mouse**

***Sigmodon hispidus***
**Cotton rat**

## Slide 31

## P maniculatus

**P maniculatus**

**P leucopus**
**Known to carry Hanta Virus in Eastern U.S.**

## Deer Mice are very persistent and creative at getting food and drink. 

**Deer Mice are very persistent and creative at getting food and drink. **

## Scat Happens.

**Scat Happens.**

**Deer Mice scat is small – rice grain sized fecal pellets.**

## Sin Nombre Virus Characteristics

**Family**
**Transmission**
**Viral particles**
**Structural ****proteins**
**Genome **

- Bunyaviridae
- vertebrate hosts,
- no arthropod vectors
- spherical, 80-120 nm
- Glycoproteins: G1, G2
- nucleoprotein: N
- ss-RNA, trisegmented,
- negative polarity

**Sin Nombre Virus Characteristics**

**Picture larger than actual object.**

**Notes:**
7.  Characteristics of Sin Nombre Virus

## Hantavirus Pulmonary Syndrome

| Most Frequent | Other | Rare |
| --- | --- | --- |
| Fever | Dizziness | Rhinorrhea |
| Myalgia | Arthralgia | Sore Throat |
| Nausea/Vomiting
Cough
 | Shortness ofBreath late in dz |  |

**Hantavirus Pulmonary Syndrome**

**Clinical  Presentation**

**Also note that most victims of HPS describe a profound deep myalgia often the worse that any of them have ever experienced, and describe feeling much worse than they clinically appear while prodromal.**

**Notes:**
10. Clinical presentation on admission.

## Hantavirus Pulmonary Syndrome Physical Examination

**  ****Tachycardia**
**  ****Hypotension**
**  ****Crackles or rales on lung ****    examination**

**Hantavirus Pulmonary Syndrome**** ****Physical Examination**

**These are LATE findings.**

## Level of Suspicion of Hanta

- Hx of Exposure
- Flu-Like prodromal illness with myalgias
*Hx of repeat presentation [possibly at different facilities] for this illness.*
-      Think of Hanta Virus in someone who has presented for ‘The Flu’ repeatedly.

## A newe kind of sickness came through the whole region, which was so sore, so peynfull and sharp, that the like was never harde of to any mannes remembrance before that time. 
                             Richard Grafton   1569

-                              Richard Grafton   1569

## English Sweate

- English 'sweate' (Sudor Anglicus) and Hantavirus pulmonary syndrome,
- The British Journal of Biomedical Science,  2001  by Bridson, Eric
- Abstract: A rapidly fatal viral infectious disease appeared in England in 1485, persisted for the summer months and disappeared as winter approached. This pattern of infection re-appeared in 1508, 1517, 1528, and finally 1551. The epidemic never returned. It had no respect for wealth or rank, and predominantly attacked males between the ages of 15 and 45 years. The incubation period was frighteningly short and the outcome normally fatal. The symptoms of acute respiratory disease and copious sweating were characteristic, providing the name `the English sweating disease'. It was never in the big league of killer epidemics, such as plague and influenza, but its pockets of instant lethality in communities gave it a special ranking of horror. The infective cause of this disease remained a total mystery until it was compared with Hantavirus pulmonary syndrome (HPS) in 1994. The strength of this theory is examined in this paper, and it is concluded that there is a close resemblance.

**HPS has probably existed wherever men and mice have met.**

## Hantavirus Pulmonary SyndromeRadiographic Findings

**  ****Bilateral alveolar infiltrates**
**  ****Pleural effusion**

**Hantavirus Pulmonary Syndrome****Radiographic Findings**

**ARDS**

## Radiographic Progression of HPS 

- May 30, 1993

- May 31, 1993

- Source: Dr. L. Ketai

**Radiographic Progression of HPS **
**in the Lungs**

**Notes:**
12.	Radiographic progression of HPS in the Lung is shown in this 	slide; these chest X-rays of a HPS patient were taken on May 27, May 30, and May 31, 1999 (courtesy of L. Ketai).  In HPS, the lung is the target organ, with a distinctive bilateral pulmonary edema due to increased vascular permeability.  The abrupt onset follows a febrile prodrome of 1 to 10 days' duration (typically 3 - 5 days).  The chest radiograph occasionally may be normal very early in the pulmonary phase of HPS, but it soon progresses to the more typical pattern of bilateral interstitial or alveolar pulmonary edema.  The findings differ from those of adult respiratory distress syndrome in that indications of interstitial edema (Kerley B lines, peribronchial cuffing) are more common and the distribution is more central in HPS. * 

## Slide 43

## ARDS

**ARDS**

## Hantavirus Pulmonary Syndrome

_**Chemistry**_
- Low albumin
- Elevated LDH
- Elevated AST (SGOT)
- Elevated ALT (SGPT)

_**Hematology**_
- Low platelet count
- Atypical lymphocytes (immunoblasts)
- Left shift on WBC differential
- Elevated hematocrit
- Elevated WBC

**Hantavirus Pulmonary Syndrome**

**Common Laboratory Findings**

**These findings, especially those in the Yellow Box, are your best bet in identifying Hanta infected patients in the late prodromal stage.**

**Notes:**
13.  Clinical laboratory presentation.

## Clinical Progression of HPS

**+**

**+**

**+**

- Fever

- Pulmonary

- edema

- Shock

- Diuresis

**Prodrome**

**Cardiorespiratory**

**Convalescence**

- Immunoblasts

- HCT

- AST

- LDH

- 3-6 days

- 7-10 days

- Platelets

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**Clinical Progression of HPS**

- 1-5 wk incubation

**Notes:**
14.	Clinical course of HPS:  There is a febrile prodrome that progresses to cardiopulmonary insufficiency.  The onset of the 	immune response precedes severe organ failure, and may mediate the vascular compromise.  In HPS, severe hypotension is usually coincident with onset of respiratory failure, which reflects the severe physiologic impact of the non-cardiogenic 	lung edema.  (AST--aspartate aminotransferase; HCT--hematocrit; LDH--lactate dehydrogenase; PTT-partial thromboplastin time.) *

## Local Experience

- June 2005
- 62 yo woman with NPH, VP Shunt, DM2 and some recent functional decline presents with vague flu-like illness

## Slide 48

##  Giant Platelets Present 

** ****Giant Platelets Present **
**  ****4 METAMYELOCYTES PER 100 WBC'S./RT**

## When her LDH was checked, it was over 700

**When her LDH was checked, it was over 700**

## Patient Transf’d

- Patient was transferred to Tertiary Care Hospital.  Went into ARDS and succumbed to an MI.
- Serologies were positive for Sin Nombre Virus.

## Summary

- Though not a classic case, she did exhibit classic lab findings and classic progression of disease.
- She had profound exposure to mouse excreta at home.

## HPS Management

- Early aggressive intensive care
- Early use of inotropic agents (Dobutamine)
- Early ventilation and PEEP
- Careful monitoring
-  Oxygenation
-  Fluid balance
-  Blood pressure

**HPS Management**

**Notes:**
15. 	HPS patient management.

## ICU Monitoring and Therapy

- Early use of inotropic agents
- Mechanical ventilation PEEP
- Judicious volume resuscitation
- ? Early PA catheter ?
- Transfer to a tertiary care facility for care by intensivists.

- SQS 6/95

**ICU Monitoring and Therapy**

**Notes:**
17.  Because of the rapid progression of the disease, it is crucial that the patient be quickly transferred to a fully-equipped 	emergency facility.  Patients should be closely and continually monitored by a physician so that appropriate intensive care measures can be performed. (Provided by Dr. Steven Simpson from University of New Mexico Hospital) 

## High Recruitment therapy for those in severe ARDS.

**High Recruitment therapy for those in severe ARDS.**

**This type of therapy available only at Tertiary Care Centers**

## Hantavirus Pulmonary Syndrome

-  	Serology
- 	IgM
- 	IgG
-  	Immunohistochemistry
-  	Reverse transcription 	and polymerase chain 	reaction (RT-PCR)

**Hantavirus Pulmonary Syndrome**

**Laboratory-confirmed  Diagnosis**

**Serologies are nice, but you ONLY have a 1% of getting a positive result in a real patient in the prodromal stage.  NOT for identifying patients in prodromal stage.**

**Available at UNM, AZ state lab.**

**Notes:**
18.	Laboratory confirmation of HPS.

## Histopathology

*Interstitial Pneumonitis*
-   Congestion
-   Interstitial infiltrate of 	 enlarged mononuclear 	 		 cells (immunoblasts)
-   Intra-alveolar and septal 	 	 edema
-   Focal hyaline membranes

**Histopathology**

**Lung (1)**

**Notes:**
20.  Main histopathologic features.

## Rodent Exposure

- Peridomestic exposure
- Peridomestic & occupational	exposure
- Peridomestic & recreational exposure	Occupational exposure
- Entering/cleaning rodent-infested structures

-  Armstrong, L.R. et al., JID 1995; 172 (October)

- 69% (48/70)
- 19% (13/70)
-   9% (6/70)
-   4% (3/70)
-   9% (6/70)

**Rodent Exposure**

**70 confirmed HPS cases**

**Notes:**
26.	Review of selected confirmed cases conducted to characterize 	rodent exposure.

## Prevalence of SNV IgG Antibodies in Select U.S. Populations

_**Risk group**_
- Forest workers1
- Health care workers2
- Prodromal HPS3
- Contacts4
- Rural OCC5
- Rodent workers6
- Total

_**Location/time**_
- SW US, 1993
- SW US, 1993
- SW US, 1993
- SW US, 1993
- SW US, 1994
- US, 1994

_**Postive/tested (%)**_
- 0/143
- 0/396
- 3/299 (1.0%)
- 3/239 (1.3%)
- 1/522 (0.2%)
- 8/932 (0.9%)
- 15/2531 (0.6%)

- 1. Vitek et al, 1996

- 2. Vitek et al, 1996

- 3. Simonsen et al, 1995

- 4. Zeitz et al, 1995

- 5. Zeitz et al, 1995

- 6. Armstrong et al, 1995

**Prevalence of SNV IgG Antibodies in Select U.S. Populations**

**Fairly low seroprevalence.**

**Notes:**
27.	Seroprevalence of SNV IgG antibodies in select occupational 	groups.

## Country				Positive/tested (%)	Time
Paraguay1				44/345 (12.8%)			1995
	Western Paraguay2  	78/193  (40.4%)			1993-1995(Indian Population)

Argentina3				<1%					1996
  Salta Province2 		38/222 (17.1%) 			1993-1995(Indian Population)

Chile3					2-13%					1997

1. Williams, 1997	 2. Ferrer, 1998        3. Peters, 1998;  Weissenbacher, 1996  	  

- Paraguay1				44/345 (12.8%)			1995
- 	Western Paraguay2  	78/193  (40.4%)			1993-1995(Indian Population)
- Argentina3				<1%					1996
-   Salta Province2 		38/222 (17.1%) 			1993-1995(Indian Population)
- Chile3					2-13%					1997
- 1. Williams, 1997	 2. Ferrer, 1998        3. Peters, 1998;  Weissenbacher, 1996

**Prevalence of SNV IgG Antibodies in Select South American Populations**

**High seroprevalence.**

## HPS Prevention

**Control Mice Inside**

**Control Mice Outside**

**Use Safety Precautions**

**HPS Prevention**

## Slide 62

## Control Mice Inside

** ****	****Eliminate food sources**
-   Wash dishes and clean the floor   	  and counters
-   Put pet food and water away at   	  night
-   Store food / garbage in containers   	  with tight lids

**Control Mice Inside**

**Notes:**
28.  Control mice inside.

## Control Mice Inside

** **

** ****Prevent mice from entering**** **
-   Clear brush and grass from 	around foundation
-  	Seal holes or use flashing 	around the base of the house
** ****Use continuous trapping efforts**

**Control Mice Inside**

## Control Mice Inside

**Control Mice Inside**

## Control Mice Outside

** ****Eliminate possible nesting sites**
-    Elevate hay, woodpiles, and 	garbage cans
-   Locate them at least 100 feet 	from house
-   Eliminate junk or things that 	provide shelter to rodents

**Control Mice Outside**

## Control Mice Outside

** ****Eliminate food sources**
-    Store all animal feed in         	containers with lids
-   Discard excess food in the 	evening into containers 	with lids
-   Take up water bowls in the 	evening

**Control Mice Outside**

## Control Mice Outside

**  ****Encourage natural predators**
-    Non-poisonous snakes
-   Owls
-   Hawks

**Control Mice Outside**

## Pets won’t give you Hanta virus, unless you have pet Peromyscus...

**Pets won’t give you Hanta virus, unless you have pet Peromyscus...**

## Use Safety Precautions

** ****	****When cleaning in areas infested with ****	****rodents**
-    Wear rubber gloves
-   Don't stir up and breathe dust
-   Wet contaminated areas with 			   		  disinfectant
-   Dispose of dead animals properly
-   Disinfect used gloves

**Use Safety Precautions**

## Slide 71

## Four Steps To Reduce Your Risk Of Getting HPS:  

**Air Out;**
**Seal Out;**
**Trap Out; and,**
**Clean Out;**** **

## Slide 73

## Slide 74

## Slide 75

## Use Safety Precautions

**   ****When enjoying outdoor activities**
-    Avoid contact with rodents
-   Stay away from rodent burrows or nests
-   Keep campsite clean and food tightly     	sealed
-   Open unused cabins and air out before     	entering or cleaning
-   Avoid sleeping on bare ground

**Use Safety Precautions**

## Slide 77

## Hantavirus Infection Sequelae

- Hantavirus Infection

- HPS

- Hantavirus Illness

**Hantavirus Infection Sequelae**

## So

- Think about it
- Ask about possible exposures
- Think platelets, LDH, ARDS
- Observation for possible cases
- Transfer for likely cases
- Avoid exposure
- Educate Patients on Prevention

## What isn’t Hanta virus?
What kind of virus is Hanta virus?
What is the reservoir and mode of spread?
Is there only one Hanta virus?
Where are Hanta viruses found?
Where does HPS occur?
What does a Deer mouse look like?
What does a Hanta virus look like?
What was it like to work at Fort Defiance in 1993?
Did Hanta virus / HPS start in 1993?
What’s the best [most common] way to catch it? 
How does HPS present?
What are common presenting symptoms, what are rare symptoms?
What is the progression of symptoms from prodrome to full HCPS?
What specific signs or lab values can be expected early on?
What other disease processes look like HCPS?

- What kind of virus is Hanta virus?
- What is the reservoir and mode of spread?
- Is there only one Hanta virus?
- Where are Hanta viruses found?
- Where does HPS occur?
- What does a Deer mouse look like?
- What does a Hanta virus look like?
- What was it like to work at Fort Defiance in 1993?
- Did Hanta virus / HPS start in 1993?
- What’s the best [most common] way to catch it?
- How does HPS present?
- What are common presenting symptoms, what are rare symptoms?
- What is the progression of symptoms from prodrome to full HCPS?
- What specific signs or lab values can be expected early on?
- What other disease processes look like HCPS?

- What is the usual prognosis?
- How should these patients be managed?
- How do you make a definitive diagnosis?
- Who gets HCPS?
- Where are they getting it?
- What has the epidemiology been over the past 10 years?
- How do we prevent HCPS?
- How should high-risk areas be cleaned?
- What should make me think ‘Hanta virus’?
- Name a Madagascari songstress?