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Hantavirus: Symptome, Ursachen und Schutz vor dem gefährlichen Erreger
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The publication conducted by the RKI guide Robert Koch Institute (RKI) on the basis of the infection protection Act § 4 (IfSG). RKI target group of professional counselors, among others, Doctors, health professionals and community health services (EGD). Information about infectious diseases important to date and focus are for orientation. Contributions will be developed in collaboration with the National Reference Center (NRC), Konsiliarlaboren (KL) and other experts. The RKI guidelines are available on the website of the Robert Koch Institute (). Freshly made counselors RKI and revised significantly next version will be published in the epidemiological Bulletin ().
First published in epidemiology Bulletin 35/2006, revision June 2015. The last update to the “legal basis” and “suggestions and special diagnostic” of February 2018.
hantaviruses is home to small mammals. When transmitted to humans, they can cause severe with different cases, depending on the species of virus diseases. So hantavirus zoonotic diseases.
In Germany, like in the West, North and Central Europe, Hantavirus infection is usually manifested as a mild form of hemorrhagic fever with renal syndrome (HFRS), which is also epidemic nephropathy (NE) is called. The symptoms are high fever, myalgia, headache, digestive disorders, and acute renal failure. In Germany was in 2012 with the symptoms of the disease were reported in 2825 (incidence: 3.5 Erkr per 100,000 population ..) So far the highest number of cases since the introduction of the Infection Protection Act (IfSG) in 2001 before. In general, however, to assume that a significant part or walk hantavirus infection have no symptoms with non-specific symptoms, so no diagnostic evaluation begins and thus lead to a lack of reporting. Outbreaks of hantavirus infections as a result of the periodic rise in population size or density corresponding reservoir rodents, especially rats bank (Myodes glareolus) and is considered the prevalence of the virus.
hantaviruses form Hantavirus genus in the family Bunyaviridae. Below the level of genus, more species of human pathogens associated virus as a host reservoir in general with a particular rodent species, differences. The most famous type virus is Hantaan, Puumala, Dobrava-Belgrade-, Seoul-, Sin-Nombre- and virus Ande
This enveloped, single-stranded RNA virus with a diameter of about 80-120 nm. virion contains three ring-shaped nucleocapsid, a virus nucleocapsid protein of the three segments of different sizes of negative-strand RNA genome and RNA polymerase molecules. The smallest segment encodes the nucleocapsid, the viral envelope glycoprotein middle segment and the largest segment of RNA polymerase. In the two envelope glycoproteins (Gn, Gc) integrated, bear certain types of antigenic determinants.
The name “Hantavirus” comes from the river Hantangang Korea. During the Korean War in the early 50s’ more than 3,000 soldiers suffering from hemorrhagic walking difficult Fiemore. The first, in 1977 isolated hantavirus, which is responsible for this disease, which was then called “Hantaan” (an extra “a” is the result of incorrect transliteration).
hantaviruses are scattered throughout the world. Due to the different distribution of reservoir hosts in each different species of hantavirus also distributed geographically different. In the Asian part of Russia, in China and on the Korean peninsula, hantaanvirus (HTNV) is endemic in the Balkans, Central Europe and the European part of Russia you will find the virus Puumala (PUUV) and virus Dobrava-Belgrade (DOBV), while in the north and Western Europe almost exclusively PUUV occur. The seoulvirus (SEOV) is said to occur throughout the world, but the distribution is not known. Hantaviruses, which happened in America, according to the host reservoirs so-called “New World” -Hantaviren. This includes the type of Sin Nombre virus (SNV), New York (NYV), Black Creek Canal (BCCV) and Bayou (BAYV), which occurs in South America Ande virus (ANDV).
In Germany, according to a study of Konsiliarlaboratoriums for hantavirus and RKI infection with Puumala virus (especially in the south and west of the country) and form Dobrava-Belgrade virus (especially in the east and north) dominant. Puumala virus infection have one of the diseases reported with information about the type of the virus so far the largest share. Regional differences Durchseuchungsgrade each rodent population affect the incidence of infection in humans. Outbreaks of hantavirus infections as a result of the periodic rise in population size or density corresponding reservoir rodents, especially rats bank (Myodes glareolus) and is considered the prevalence of the virus.
The number of national Hantavirus is transmitted by IfSG controlling the disease varies greatly from year to year: While 233 cases were filed in 2001 and 2004, 2006, 2008, 2009, 2011, 2013 and 2014 on average, are years- 2005, 2007, 2010 and 2012 respectively rising epidemic of Puumala virus infections in certain regions of Germany affected. The outbreak areas, each with variants distinguished Puumalavirus molekularepidemiologisch especially in the Swabian Alb, the Bavarian Forest, the Spessart, in northeastern Hesse, Teutoburg Forest and Münsterland.
The original infection with virus Dobrava Belgrade carried out in Germany by the genotype of the virus Kurkino, the field mice (Apodemus agrarius) house. Mouse original fire just north and east of the country, which explains, is that infection with the virus in the country focus section.
More than two-thirds of the patients were male, and including in turn over half of the age group of 30-49 year olds. The average prevalence in the general population is 1% in Germany
A third occurred in Germany Hantavirus -. The Tulavirus – is the current knowledge of pathogens, only a little for humans. Seroepidemiological studies in humans have evidence of individuals Tulavirus-reactive sera, but so far only one case of the disease in combination with the transition Tulavirus infection known in Germany. The mice (Microtus arvalis) as a reservoir Tulavirus found throughout Germany.
Currently, the number of cases and further epidemiological characteristics of all illnesses reported can be found in the current Yearbook Infectious below. A simplified database according IfSG disease cases should be reported and the detection of pathogens can be interrogated with the help below.
Because of the specific symptoms and a high proportion of courses with less symptoms of the disease from a high number of unreported cases to go.
Unlike other Bunya (Orthobunya-, Nairo-, Phlebovirus) infection with hantaviruses not by arthropods (such as sand fleas, ticks and mosquitoes), but the pathogens are asymptomatic excretions of infected rodents (especially rats and mice ) transferred to humans. The occurrence of hantaviruses bound to the distribution area suitable host animal. Thus one of the findings in AMerica hantaviruses human pathogen transmitted by representatives of the subfamily “New World” (Sigmodontinae). In Europe and Asia, representatives of the “real rat” (Murinae), also referred to as “murinae” shape and “Vole” (Arvicolinae) reservoir for hantaviruses. Each species has a specific host hantavirus reservoir itself which only consists of one or more closely related species of rodent. Reservoir Puumalavirus that Rötelmaus of virus Dobrava-Belgrade, there are various species of Apodemus – fire rat (Apodemus agrarius), mouse yellow-necked (Apodemus flavicollis) and the Black Sea wood mice (Apodemus Ponticus) – (mouse hantaanvirus fire, various species of seoulvirus Rattus norvegicus , Rattus rattus), Sin Nombre virus, deer mouse (Peromyscus maniculatus) and Ande rice rat virus (Oligoryzomys longicaudatus).
recently, new hantaviruses have been hosted previously unknown reservoirs such as rats, moles and bats detected. In Central Europe, this is Seewisvirus and Asikkalavirus (acting as a reservoir species rat) and virus Nova (reservoir mol) is. Whether this newly discovered viruses are pathogenic for humans is unknown.
The virus is excreted by infected rodents through saliva, urine and feces and can in fact, remain infectious for several days in a dry state. Transmission to humans occurs through inhalation of virus-containing aerosols (eg Dust raised) with injured skin contact with contaminated material (eg, dust, dirt) or with a bite. Also the transmission through food contaminated with infected secretions mice, may
The incubation period is usually 2 -. 4 weeks, in exceptional cases, they may be only 5 days or up to 60 days
Most of hantavirus infections are asymptomatic or with non-specific symptoms, so often there is no diagnostic evaluation begins. Depending on the type of virus causing hantaviruses can cause a variety of serious diseases. The disease usually begins with a sudden onset of fever, 3 – lasted four days. Accompanying occur nonspecific flu-like symptoms such as headache and myalgia. Asian and European hantavirus strains that trigger hemorrhagic fever with renal syndrome (HFRS). The latest results also show cases of HFRS by hantavirus infection in Africa. In infections that occurred in Germany type virus (Puumala and Dobrava-Belgrade virus) real hemorrhagic course very rare and there are flu-like symptoms, and renal involvement in the foreground. This wave is called by some authors as epidemic nephropathy (NE). Hantaviruses from North and South America cause hantavirus induzierte- (cardiovascular) pulmonary syndrome (HPS or HCP). Because the pathogenesis and clinical picture of overlap both syndromes received lately more and more to speak in hantavirus disease. After experiencing an infection may result in a lifetime, virus type-specific immune
appearances with some of the following symptoms may indicate possible hantavirus disease (HFRS) point.
The suspect should be investigated serologically
illness usually begins suddenly with a high fever, 3 -. lasted four days. The first is a general non-specific symptoms such as chills, joint and headache, photophobia, blurred vision, redness of the throat and cough in the foreground. A few days later pronounced low back pain, abdominal pain, dizziness, diarrhea and vomiting occurs in most patients. This phase is characterized by hypotension leading to shock and other hemostatic disorders that may manifest themselves in, for example, bleeding of the conjunctiva and skin petechiae. In the course there is an increased renal retention values ​​up to dialysis renal insufficiency. Phase polyurische start the recovery period. It can last for several weeks and is accompanied with renal hypertension. The mortality rate of moderate to severe forms of HFRS is 5-15%
In some cases, it could at extrarenal Manifestatione HFRS patients.Watch n, for example hepatitis accompanying and isolated myocarditis, thyroiditis or CNS involvement. Also pulmonary symptoms may occur during HFRS so (see below) is not just a typical induction Neuweltviren HPS / HCP.
The most frequently observed in Germany, clinically mild to moderate forms of HFRS progressive (by some authors also called epidemic nephropathy), principally over HFRS stadium, but they are less pronounced. It runs more than flu-like disease with renal involvement. Renal dysfunction presented with hematuria, proteinuria, and – in severe cases – kidney failure. Bleeding is rare, causing severe hypotension shock is usually lost. lethality is a disease caused by infection PUUV below 1%, so by DOBV infection (genotype Kurkino) was 0.3 to 0.9% is determined. Incidentally, there is also DOBV variants that occur outside of Germany and serious illness with 10 deaths – the cause of 15%; This is the genotype Dobrava (Reservoir is yellow-necked mice, Apodemus flavicollis) and genotype Sochi (Reservoir is the Black Sea wood mouse, Apodemus Ponticus).
HPS / HCP is characterized by sudden, high fever starts with non-specific symptoms such as nausea, vomiting, myalgia, weakness, dizziness, abdominal pain. In a later phase of 4-10 days after the onset of symptoms of cough, dyspnea and tachyarrhythmias occurred. Coming to cardiopulmonary decompensation with infiltration of the lung (pulmonary edema) and the development of rapidly progressive respiratory distress syndrome (ARDS). The lethality is the shape of the course in 25 -. 40%
A hantaviruses transfer from person to person in Europe and Asia do not take any kind of virus prevalent. So far only exists in a very deadly virus occurred in South America Ande indication of possible transmission from person to person. Hantaviruses can remain infectious for several days outside the host organism as a function of temperature, humidity and other conditions.
The diagnosis of hantavirus infection is usually awarded on the basis of clinical and serological findings already give an indication serotypes (species of virus).
The second laboratory diagnosis
To this day serological diagnosis of IgM and IgG enzyme-linked immunosorbent assay (ELISA) is recommended. As a rule, patients in early clinical symptoms of IgM antibodies, antibody IgA and IgG antibodies are usually already have. For a reliable serological diagnosis, the detection of IgG or IgM and IgG antibody titer rise in paired sera is required. Also immunoblotting and immunofluorescence assay (IFA) can be used for diagnostics. Confirmation of doubtful ELISA results by an independent method for the detection of antibodies (immunoblot IFA) is recommended. IgM antibodies can be for about 1 normally – 3 months after disease onset showed, in individual cases, but also for a number of years. IgG antibodies may persist for life.
Using a virus neutralization test at a specialized laboratory (security level 3) is performed, a certain serotypes is possible. The final classification of the infecting virus strain based on analysis of the nucleotide sequence of the genome segments. Viremik phase short because only a few days of ribonucleic acid (RNA) in the blood detection by the polymerase chain reaction (PCR), but promises success only in the early stages of the disease, or negative PCR result does not exclude isolated hantavirus infection. Also usually not enough reference samples stored frozen from early stage clinical, of the amplified nucleic acids can exist. It is advisable to immediately asservieren material for PCR analysis possible with clinical suspicion of hantavirus infection.
Hantavirus disease is treated the symptoms. This may include intensive treatment to control bleeding, and for stabilization circuitry as well as the treatment of acute renal insufficiency using dialysis or intubation and mechanical ventilation for Therapie ARDS. In some cases, the Early antiviral chemotherapy
Currently, no licensed vaccine proved with ribavirin as a success. Nor is specifically directed against the pathogen therapy. Therefore, the exposure prophylaxis is the most important measure for preventing hantavirus infection
The most effective protection against infection is to avoid contact with rat droppings -. In Germany in relation to the type of virus that applies here especially sanguine and rats fire. In the region lifelike environment (especially basements, attics, warehouses, etc.) must be fought intensively rats and general hygiene measures are followed. This is particularly important for safe storage of food, so that the animals do not lie around the house or apartment. When handling dead mice or those living in areas contaminated with rat specific protective measures must be complied with, for example, can be avoided by wetting the dust may be in the contaminated areas. When expecting to dust respirator and gloves should be worn. dead mice and droppings should be wetted with disinfectant before disposal.
More information about avoiding hantavirus infection is common leaflets Konsiliarlabors for hantaviruses in Charite in Berlin, Robert Koch Institute and other institutions, “How do I avoid hantavirus infection” (see below for more information).
risk of infection is of particular individuals living and working conditions supportive contact with infected rodents and dirt or those who are in direct contact with the virus, for example, forest workers, agricultural workers and laboratory personnel. You have to be very aware of the transmission lines and protection measures.
A separation of affected individuals is not required.
As a human to human transmission of hantaviruses in Europe and Asia do not take any kind of public place of the virus, there are no special measures for the necessary contacts.
disease of some people from home or working in the same environment can be a common source of infection, particularly exposure to rodents, near which must be fought intensively.
health department. in accordance with § 6 paragraph 1 no. 1 IfSG suspected disease, illness and death dengue virus-induced and according to § 7 paragraph. 1 IfSG direct or indirect detection of hantaviruses, as far as he was to show an acute infection, especially reported.
message have the health department no more than 24 hours of acquired knowledge.
in § 8 IfSG be named declaration (). In § 9 IfSG specify what information must include a report absences to the health department ().
The Department of Health received pursuant to § 11 paragraph. 1 IfSG to the competent state authorities any illness or death and detection of pathogens that meet the case definition according to § 11 paragraph. 2 IfSG.
case definitions created by the Robert Koch Institute, published on the website of the Robert Koch Institute in
Robert Koch Institute have for the individual medical advice. clinic, therapy or vaccination. Please contact in this case the doctor or clinic in your area, where there is specialization in infectious diseases possible.
As for the question about infection control and prevention, please contact your local health department ().
Field of 35 – for Gastroenterological infections, zoonoses and tropical infections
Contact: Prof. Dr. Klaus Stark
Tel :. 030 18754 3432
consulting laboratory for hantavirus
Charite – Berlin UNIVERSITÄTSMEDIZIN
Contact: Prof. Dr. Joerg Hofmann (Head); Prof. Dr. Detlev H. Kruger; Dr. Sabrina White
Tel: 030-405-026-351 ;. 030450525-092; 030450525-089
Fax: 030-405-026-616; 030450525-907
E-mail:; ;
Notes on the series “RKI guidelines” should be directed to the Robert Koch Institute, Department of Infectious Disease Epidemiology, Dr. astrid Mil02/07/2015
Robert: or editor of epidemiological Bulletin ()
Stand; de-Busch (Tel :. 030 18 754 3312). Koch Institute is a federal agency in the federal Ministry of Health
OF THE unless explicitly stated otherwise.
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