24 April 2008
An increase in reported cases of haemorrhagic fever with renal syndrome in Slovenia in early 2008
- Communicable Disease Centre, National Institute of Public Health, Ljubljana, Slovenia
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Slovenia
Citation style for this article: Koren N, Grilc E, Blaško M, Avsic T, Kraigher A. An increase in reported cases of haemorrhagic fever with renal syndrome in Slovenia in early 2008. Euro Surveill. 2008;13(17):pii=18846. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=18846
Date of submission:
21 April 2008
Haemorrhagic fever with renal syndrome (HFRS) is an acute zoonotic viral disease, caused by hantaviruses. Hantaviruses infect rodents worldwide. They are transmitted to humans by aerosol from rodent excreta. Several hantaviruses are known to infect humans with varying severity.
In Europe, three hantaviruses pathogenic for humans are well documented. Puumala virus (PUUV) carried by C. glareolus (bank vole) and causing a milder form of HFRS (Nephropathia epidemica) is reported throughout Europe and western Russia . Dobrava virus (DOBV) is carried by Apodemus flavicollis, the yellow-necked filed mouse, and is associated with a severe form of a disease with up to 12 % mortality in the Balkans [2,3]. Saaremaa virus (SAAV) is carried by Apodemus agrarius, the striped field mouse, and is found in the Baltic and Central Europe causing mild HFRS similar to PUUV infection [4,5,6].
The first hantavirus infection was diagnosed in Slovenia in 1952. Both severe and mild clinical courses of the disease have been observed, with an overall lethality rate of 4.5 percent . We have demonstrated that DOBV and PUUV co-exist in a single endemic region of Slovenia and are capable of causing HFRS with significant differences in severity . Earlier epidemiological surveys indicated that A. flavicollis and C. glareolus, which are common rodent species throughout central Europe, were most often infected with hantaviruses [8,9,10].Notification of all hantavirus infections has been mandatory in Slovenia since 1978. They are reported to regional institutes of public health as HFRS (in the following text, all hantavirus infections caused by PUUV or DOBV will be addressed as HFRS). As of 16 April, 11 sporadic cases of HFRS have been reported in Slovenia (two in January, one in February, five in March, and three more until 16 April). This represents an early increase of reported HFRS cases (Figure 3). There were 14 cases of HFRS in the whole of 2007, and only two cases were reported in the same period last year (both in April).
All the cases reported this year have been from five of Slovenia’s nine health regions: Ljubljana, Celje, Kranj, Maribor and Novo mesto (Figure 1). Two patients are women, nine are men . They are 34 to 75 years old.
Figure 1. Geographic distribution of reported hantavirus infections caused by Dobrava and Puumala, Slovenia, 1 January to 16 April 2008
Laboratory diagnosis (indirect immunofluorescent antibody (IFA) test for the detection of human serum IgG antibodies and ELISA for the detection of human serum IgM antibodies) of all HFRS cases was performed by the Institute of Microbiology and Immunology at the Medical Faculty in Ljubljana. In nine cases, the infectious agent was Puumala and in two Dobrava. The causative virus was indentified by using RT-PCR method in acute serum samples [11,12].
Some information about possible exposure is available for nine cases of HFRS (9/25 (25 = 14 from 2007 and 11 from 2008) =36%) reported in 2007 and 2008: three of them worked in the field, four had contact with rodent excreta or direct contact with rodents at home and two patients had direct contact with rodents at their workplace.
In the last 10 years, zero to 27 HFRS cases were reported annually. Figure 2 shows the number of reported HFRS cases between 1999 and 2008.
Figure 2. Number of reported hantavirus infections caused by Dobrava and Puumala in Slovenia (1998-2008*; n = 111)
More cases than usual are expected this year due to an early increase of cases in the first three months of 2008 and because the usual season of HFRS in Slovenia has only just begun. In previous years, most cases were reported in late spring and summer (Figure 3). The increase of cases in early 2008 has probably been as a result of a mild winter and its impact on the rodent population [13,14].
Figure 3. Monthly distribution of reported hantavirus infections caused by Dobrava and Puumala in Slovenia in 2008* (n=11), monthly distribution for 10 years (n=100) and 5 years (n=55) average and monthly distribution of average of two years with highest number of reported cases since the 1990s, when the electronic database was launched**
Information about this increased occurrence of HFRS cases has been sent to regional public health doctors, general practitioners, infectologists, nephrologists and pediatricians. Rodent control in and around the home remains the primary strategy in preventing hantavirus infection. Therefore, general precautions to limit exposure to rodents have been stressed in communications with the media.
Precautions to limit exposure to rodents include:
- Interiors and exteriors of houses should be carefully inspected at least twice a year for any openings in which rodents could enter and for conditions that could support rodent activity , such as the possibility to store food or organic waste not kept in a rodent-proof manner;
- Inside the home, food, including pet food and water, should be kept in rodent-proof containers, while dishes and cooking utensils should be washed immediately after use.
- Leftover food should be cleaned up;
- Trash and garbage should be disposed on a frequent and regular basis;
- Safe methods to dispose of rodents’ excreta and dead animals should be used.
If rodent infestation is severe or persistent, a pest control professional for rodent eradication should be called.
- Brummer-Korvenkontio M, Henttonen H, Vaheri A. Hemorrhagic fever with renal syndrome in Finland: ecology and virology of nephropathia epidemica. Scand J Infect Dis Suppl. 1982;36:88-91.
- Avsic-Zupanc T, Petrovec M, Furlan P, Kaps R, Elgh F, Lundkvist A. Hemorrhagic fever with renal syndrome in the Dolenjska region of Slovenia--a 10-year survey. Clin Infect Dis. 1999 Apr;28(4):860-5.
- Papa A, Johnson AM, Stockton PC, Bowen MD, Spiropoulou CF, Alexiou-Daniel S, Ksiazek TG, Nichol ST, Antoniadis A. Retrospective serological and genetic study of the distribution of hantaviruses in Greece.
- Golovljova I, Sjölander KB, Lindegren G, Vene S, Vasilenko V, Plyusnin A, Lundkvist A. Hantaviruses in Estonia. J Med Virol. 2002 Dec;68(4):589-98.
- Sjölander KB, Golovljova I, Vasilenko V, Plyusnin A, Lundkvist A. Serological divergence of Dobrava and Saaremaa hantaviruses: evidence for two distinct serotypes. Epidemiol Infect. 2002 Feb;128(1):99-103.
- Golovljova I, Vasilenko V, Mittzenkov V, Prükk T, Seppet E, Vene S, Settergren B, Plyusnin A, Lundkvist A. Characterization of hemorrhagic fever with renal syndrome caused by hantaviruses, Estonia. Emerg Infect Dis. 2007 Nov;13(11):1773-6.
- Avsic-Zupanc T, Petrovec M. Hantavirus infection in Slovenia. Update in pathology / 19th European Congress of Pathology, Ljubljana, Slovenia, September 6-11, 2003 [and] Nephropathology Pre-congress Meeting Advances in Nephropathology, September 6, 2003 [and] Pulmonary Pathology Pre-congress Meeting, September 6, 2003.- Ljubljana : Faculty of Medicine, Institute of Pathology, 2003; 261-262.
- Avsic-Zupanc T. HFRS in the Balkans. In: H.W. Lee, C.H. Calisher and C.S. Schmaljohn, Editors, Manual of hemorrhagic fever with renal syndrome and hantavirus pulmonary syndrome. Seoul : WHO Collaborating Center for Virus Reference and Research (Hantaviruses), 1998; 60-62.
- Avsic-Zupanc T, Toney A, Anderson K, Chu YK, Schmaljohn C. Genetic and antigenic properties of Dobrava virus: a unique member of the Hantavirus genus, family Bunyaviridae. J Gen Virol. 1995;76( Pt 11):2801-8.
- Avsic-Zupanc T, Poljak M, Lavrenčak J, Kryštufek B and Trilar T. Study of molecular epidemiology of Hantavirus infection in small mammals by polymerase chain reaction. Program and abstracts of the joint annual meeting of the American society of tropical medicine and hygiene and the American society of parasitology. Suppl. to: The American journal of tropical medicine and hygiene, 49: 195.
- Avsic-Zupanc T, Petrovec M, Duh D, Plyusnina A, Lundkvist A, Plyusnin A.Puumala hantavirus in Slovenia: analyses of S and M segment sequences recovered from patients and rodents. Virus Res. 2007 Feb;123(2):204-10. Epub 2006 Sep 25.
- Saksida A, Duh D, Korva M, Avsic-Zupanc T. Dobrava virus RNA load in patients who have hemorrhagic fever with renal syndrome. J Infect Dis. 2008 Mar 1;197(5):681-5.
- Koch J, Brockmann SO, Winter C, Kimmig P, Stark K. Significant increase of hantavirus infections in Germany since the beginning of 2007. Euro Surveill. 2007;12(18):pii=3185. Available from: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3185
- Linard C, Tersago K, Leirs H, Lambin EF. Environmental conditions and Puumala virus transmission in Belgium. Int J Health Geogr. 2007 Dec 14;6:55.
- Mills J, Corneli A, Young JC, Garrison LE, Khan AS, Ksiazek DVM. Hantavirus Pulmonary Syndrome – United States, Updated Recommendations for Risk Reduction. Morbidity and Mortality Weekly Report 2002;5:1-12.