Update: Hantavirus Infection -- United States, 1993

An outbreak of respiratory illness associated with hantavirus infection continues to be investigated by state health departments in Arizona, Colorado, New Mexico, and Utah; the Indian Health Service; and CDC, with the assistance of the Navajo Nation Division of Health (1-4). This report updates information regarding the outbreak and presents information on a case of unexplained adult respiratory distress syndrome (ARDS) in a person who resided in eastern Texas.

Laboratory evidence of acute hantavirus infection has been confirmed in 16 patients who had onset of illness from January 1 through June 30, 1993. Of these 16 cases, 11 occurred in New Mexico, four in Arizona, and one in Colorado; 12 occurred among persons aged 20-40 years. Twelve patients have died. Similar illnesses in an additional 25 persons in the four-state area, 10 of whom died, are being investigated for possible hantavirus infection.

In June 1993, a fatal case of ARDS occurred following a prodrome of fever, myalgias, and shortness of breath in a previously healthy 58-year-old woman who lived in eastern Texas. The woman had not traveled outside eastern Texas during the 3 months before her illness. During her hospitalization, diagnostic evaluation, including blood and sputum cultures and a transbronchial lung biopsy, did not reveal the cause of her illness. A serologic test conducted at CDC on a single serum specimen revealed an elevated hantavirus immunoglobulin M enzyme-linked immunosorbent assay titer. The Texas Department of Health and CDC are continuing to investigate this illness by examining clinical materials using additional techniques and seeking evidence of hantavirus infection in rodents in the vicinity.

Except for illnesses in the Texas patient described in this report and in a person who had traveled to the four-state area in 1992 (4), no evidence of hantavirus infection has been detected in serologic tests conducted at CDC on specimens from 22 other persons with unexplained ARDS who resided outside the four-state area.

Reported by: MJ Burkhardt, MPH, Secretary of Health, N Kalishman, MD, M Gallaher, MD, R Voorhees, MD, M Samuel, DrPH, M Tanuz, G Simpson, MD, L Hughes, PhD, E Umland, MD, G Oty, MS, L Nims, MS, CM Sewell, DrPH, State Epidemiologist, New Mexico Dept of Health. K Komatsu, MPH, C Kioski, MPH, K Fleming, MA, J Doll, PhD, C Levy, MS, TM Fink, P Murphy, B England, MD, M Smolinski, MD, B Erickson, PhD, W Slanta, L Sands, DO, Acting State Epidemiologist, Arizona Dept of Health Svcs. P Shillam, MSPH, RE Hoffman, MD, State Epidemiologist, Colorado Dept of Health. S Lanser, MPH, CR Nichols, MPA, State Epidemiologist, Utah Dept of Health. B Ray, KA Hendricks, MD, DM Simpson, PhD, State Epidemiologist, Texas Dept of Health. L Hubbard-Pourier, MPH, Div of Health, Navajo Nation, Window Rock, Arizona. J Cheek, MD, A Craig, MD, R Haskins, MPH, B Muneta, MD, B Tempest, MD, M Carroll, MD, LA Shands, MPH, JP Sarisky, MPH, RE Turner, P Bohan, MS, Indian Health Svc. Div of Field Epidemiology, Epidemiology Program Office; Div of Bacterial and Mycotic Diseases, Div of Vector-Borne Infectious Diseases, Scientific Resources Program, and Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The findings of the investigation described in this report suggest that acute hantavirus infection occurred in a resident of eastern Texas. This case suggests that ARDS associated with acute hantavirus infection can occur in areas outside the southwestern United States. CDC continues to work with state health departments to investigate cases of unexplained ARDS.

The current outbreak appears to be caused by a newly recognized hantavirus associated with Peromyscus maniculatus (deer mouse). Previously, two well-characterized hantaviruses had been isolated from different species in the United States: Seoul virus from Rattus norvegicus (Norway rat) and Prospect Hill virus from Microtus pennsylvanicus (meadow vole) (5). Antibodies reactive with these viruses have been detected in serum specimens from rodents and humans from many areas of the United States (5).

A previous report suggests that the prevalence of hantavirus-specific antibodies is low in humans in the United States (6). However, examination of the association of hantavirus infection with human disease in the United States has been limited and focused on renal disease, which is characteristic of previously described hantavirus syndromes, but not on pulmonary disease, which is characteristic of the syndrome in the current outbreak (7). In one recent study, serologic evidence of past hantavirus infection was associated with a diagnosis of hypertensive renal disease (6). Additional research is needed to define the distribution and manifestations of hantavirus infections in the United States.

References

1. CDC. Outbreak of acute illness -- southwestern United States, 1993. MMWR 1993;42:421-4.

2. CDC. Update: outbreak of hantavirus infection -- southwestern United States, 1993. MMWR 1993;42:441-3.

3. CDC. Update: outbreak of hantavirus infection -- southwestern United States, 1993. MMWR 1993;42:477-9.

4. CDC. Update: outbreak of hantavirus infection -- southwestern United States, 1993. MMWR 1993;42:495-6.

5. Yanagihara R. Hantavirus infection in the United States: epizootiology and epidemiology. Rev Infect Dis 1990;12:449-57.

6. Glass GE, Watson AJ, LeDuc JW, Kelen GD, Quinn TC, Childs JE. Infection with a ratborne hantavirus in US residents is consistently associated with hypertensive renal disease. J Infect Dis 1993;167:614-20.

7. LeDuc JW, Childs JE, Glass GE, Watson AJ. Hantaan (Korean hemorrhagic fever) and related rodent zoonoses. In: Morse SS, ed. Emerging viruses, 1993. New York: Oxford University Press, 1993:149-58.

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