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      Notes from the Field: Hantavirus Pulmonary Syndrome in a Migrant Farm Worker — Colorado, 2016

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          Abstract

          On August 8, 2016, Tri-County Health Department (Adams, Arapahoe, and Douglas counties) in Colorado was notified of a confirmed case of hantavirus pulmonary syndrome (HPS). The patient was a previously healthy male migrant farm worker aged 25 years, living in farm quarters, and working in vegetable fields for 8 weeks before symptom onset. On July 20, he experienced sudden onset of fever, severe headache, myalgias, cough, and nosebleed. He was evaluated at an emergency department on July 23, where his temperature was 103.9°F (40.0°C), and his physical exam was notable for bronchial breath sounds and pulmonary crackles. Chest radiograph revealed bilateral interstitial infiltrates and small pleural effusions, and thrombocytopenia (47,000/μL) was a noted laboratory finding. The patient was hospitalized for 3 days, required minimal oxygen and supportive care, and survived. Serology obtained on hospital admission was positive for hantavirus immunoglobulin M (IgM) and immunoglobulin G antibodies, with a positive result for Sin Nombre virus (SNV) (the primary etiologic agent of HPS in the United States) IgM at 1:6400, consistent with acute infection (Table). TABLE Laboratory findings associated with hantavirus pulmonary syndrome and Sin Nombre virus infection in a patient, by specimen collection date — Colorado, July 2016 Clinical specimen and laboratory test Reference range Collection date July 23 July 24 July 26 Hantavirus IgM antibodies (ELISA)* <2.00 —† 7.13 —† Hantavirus IgG antibodies (ELISA)* <2.00 —† 10.05 —† Sin Nombre virus IgM antibodies (ELISA)§ <1:100 —† 1:6400 —† Sin Nombre virus IgG antibodies (ELISA)§ <1:100 —† 1:100 —† Sin Nombre virus IgM antibodies (ELISA)*,¶ <0.80 —† 4.83; 4.01 —† White blood cells (103/μL) 4.8–10.8 7 8.9 9.4 Hematocrit (%) 42.0–52.0 49 44 43 Platelets (103/μL) 130–400 47 59 144 Abbreviations: ELISA = enzyme-linked immunosorbent assay; IgG = immunoglobulin G; IgM = immunoglobulin M. * Commercial reference laboratory. † Data not collected. § Colorado State Department of Public Health and Environment laboratory. ¶ Confirmatory reflex testing was performed twice. Hantaviruses are a genus within the Bunyaviridae family that can cause HPS, a rare and sometimes fatal respiratory disease in humans. The majority of HPS cases in the United States are caused by SNV, which is primarily transmitted by the deer mouse (Peromyscus maniculatus) ( 1 ). The average incubation period is 1–5 weeks after exposure to infected deer mouse urine or droppings ( 2 ). HPS typically manifests with fever, myalgias, progressive respiratory insufficiency, thrombocytopenia, and leukocytosis. Treatment is supportive. Approximately 60% of hospitalized patients experience pulmonary edema and respiratory failure and require mechanical ventilation ( 3 ). HPS case-fatality ratio is 38% ( 4 ). Tri-County Health Department performed an environmental assessment of the farm on August 17. The residential dwelling was shared with 12 other male farm workers in a 1,000 square-foot wood frame house. Open food containers were found throughout the house; rodent droppings were observed in the kitchen, cement foundation, and ceiling. The patient reported that during the incubation period, he took daytime naps under trees and in abandoned farm buildings on the property, information that was corroborated by the farm owner and foreman. Those napping areas had evidence of rodent habitation including nesting, burrowing, and rodent runs. None of the other housemates reported an acute respiratory illness during the same exposure period and were not medically evaluated. Tri-County Health Department recommended implementing an integrated pest management program in the residential dwelling and workplace, which the farm owner agreed to execute. Review of HPS cases in Tri-County Health Department’s jurisdiction during the preceding 2 years revealed a fatal case in a farm worker in November 2014 (Colorado Electronic Disease Reporting System, unpublished data, 2016) on a ranch approximately 50 miles east of the farm described in this report. Environmental assessment of that patient’s farm home in 2014 revealed multiple rodent nests and excrement throughout the rural residential dwellings. This report highlights the importance of considering HPS in farm workers and in other occupations with risk for rodent exposure either at the workplace or in housing provided by the employer ( 5 , 6 ). Nationally, 23% of reported HPS cases with a reported occupation were working in agriculture (Dr. Annabelle de St. Maurice, CDC, personal communication, 2016). The lack of a vaccine or specific treatment for HPS underscores the importance of focusing on behavioral and environmental risk reduction to prevent SNV infections, including for at-risk occupations, such as farming. Adding supplemental questions to the national HPS case report form* about occupational exposures, including occupation, industry, workplace, and work-related housing or other outdoor activities, will improve identification of work practices and characteristics that increase risk for SNV exposure. Rapid public health assessment of environmental exposure to SNV is critical to mitigate ongoing hazards.

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          Diagnosis and treatment of new world hantavirus infections.

          The purpose of this review is to summarize the current knowledge regarding the diagnosis and treatment of indigenous new world hantavirus infections. Recent studies have defined the incubation period of new world hantavirus infections, provided additional evidence for person-to-person transmission of Andes virus, described a rapid method for the presumptive diagnosis of infection in the cardiopulmonary phase through a review of the peripheral smear, and suggested that intravenous ribavirin is probably not effective for the treatment of new world hantavirus infections when started in the cardiopulmonary phase. Presumptive diagnosis may be made by a review of the peripheral blood smear after the onset of the cardiopulmonary phase. Critical care management includes the avoidance of fluid overload, pressors to maintain cardiac output, and the use of extracorporeal membrane oxygenation in the most severe cases, but treatment with intravenous ribavirin is probably not effective.
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            Twenty-Year Summary of Surveillance for Human Hantavirus Infections, United States

            In the past 20 years of surveillance for hantavirus in humans in the United States, 624 cases of hantavirus pulmonary syndrome (HPS) have been reported, 96% of which occurred in states west of the Mississippi River. Most hantavirus infections are caused by Sin Nombre virus, but cases of HPS caused by Bayou, Black Creek Canal, Monongahela, and New York viruses have been reported, and cases of domestically acquired hemorrhagic fever and renal syndrome caused by Seoul virus have also occurred. Rarely, hantavirus infections result in mild illness that does not progress to HPS. Continued testing and surveillance of clinical cases in humans will improve our understanding of the etiologic agents involved and the spectrum of diseases.
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              Hantavirus infection in North America: a clinical review.

              The recent outbreak of hantavirus in Yosemite National Park has attracted national attention, with 10 confirmed cases of hantavirus cardiopulmonary syndrome and thousands of more people exposed. This article will review the epidemiology, presentation, workup, and treatment for this rare but potentially lethal illness. The possibility of infection with hantavirus deserves consideration in patients with severe respiratory symptoms with rodent exposure or rural/wilderness travel. Accurate diagnosis requires a high index of suspicion. Hantavirus cardiopulmonary syndrome presents as a vague prodrome of fever, cough, myalgias, chills, and nausea followed by a rapidly worsening respiratory phase. Presumptive diagnosis can be made based on pulmonary interstitial edema on chest radiographs in association with leukocytosis, thrombocytopenia, and hemoconcentration. Suspected cases should be confirmed with a reference laboratory and reported to the appropriate public health authorities. Although treatment is primarily supportive, aggressive fluid administration should be avoided due to the risk of pulmonary edema. The cardiopulmonary phase of the disease can progress rapidly with catastrophic decompensation in as little as a few hours. Patients require rapid intensive care unit admission for monitoring, mechanical ventilation, vasoactive agents, and possibly extracorporeal mechanical ventilation. Emergency physicians should be aware of outbreaks and vigilant for hantavirus exposures, especially during the summer and early fall months. Published by Elsevier Inc.
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                Author and article information

                Journal
                MMWR Morb Mortal Wkly Rep
                MMWR Morb. Mortal. Wkly. Rep
                WR
                MMWR. Morbidity and Mortality Weekly Report
                Centers for Disease Control and Prevention
                0149-2195
                1545-861X
                20 January 2017
                20 January 2017
                : 66
                : 2
                : 62-63
                Affiliations
                Epidemic Intelligence Service, Division of Scientific Education and Professional Development, CDC; Tri-County Health Department, Greenwood Village, Colorado.
                Author notes
                Corresponding author: Grace Marx, gmarx@ 123456cdc.gov , 720-200-1683.
                Article
                mm6602a6
                10.15585/mmwr.mm6602a6
                5657654
                28103211
                b95999bf-1867-4668-abbb-63dd7bc71113

                All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

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