Transcript KOREAN HEMORRHAGIC FEVER An Ever Present Danger to U.S. Forces Korea COL (Ret) Terry A.

KOREAN HEMORRHAGIC
FEVER
An Ever Present Danger
to U.S. Forces Korea
COL (Ret) Terry A. Klein, PhD
Regional Emerging Infectious Disease Consultant
Force Health Protection, 18th Medical Command
13 February 2007
Collaborators
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Dr. Jin-Won Song, Korea University
Dr. Luck-Ju Baek, Korea University
Dr. Heung-Chul Kim, 5th MED DET
LTC William Sames, 18th MEDCOM
LTC Douglas Burkett, Air Force
LTC Monica O’Guinn, USAMRIID
MAJ John Lee, USAMRIID
MAJ Anthony Schuster, CHPPM
Commanders and Personnel, MED DETS
Rodent-borne Disease
Surveillance
Purpose: Reduce the impact of rodent-borne
diseases
Background: >400 cases of HFRS annually
Problem: Rodent-borne diseases often
“epidemic”.
Benefits: Increase “early warning” potential
Surveillance: HFRS, murine typhus, scrub
typhus, and leptospirosis
Environmental modifications: Affects
population and disease potential of emerging
infectious diseases
Introduction
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Hantaviruses are worldwide
HFRS (KHF) is a viral disease
Maintained by rodent reservoirs
Ranges in severity from mild to fatal
Prevention is the best measure
If prevention fails, requires rapid
treatment/supportive care (ribovirin)
• Risks related to occupation and behavior
• No US approved vaccine
HFRS Transmission
• Respiratory via aerosolized rodent
secreta/excreta (3 - 8% mortality)
• No horizontal human to human
transmission
• 2,422 US cases during Korean war
• Prevention requires good field
sanitation
• Early supportive treatment required
Number of Korean Hemorrhagic Fever
Cases in ROK Personnel, 1986 - 2006
500
USFK *
ROK Civilian
ROK Military
450
400
392
350
427 431 415
323 336
300
250
215
200
150
196 203
132
118 104
109
106
103
95
89
79 85 76
55 58
52 50 61
46
37
26
27
23 9 24 16 15 9
6 9 6 0 2 0 8 4 23
3 4 3 0 3 10
1 4
0 04 0
100
50
0
'88
'89
'90
'91
'92
'93
'94
'95
'96
'97
'98
'99
'00
'01
'02
'03 '04
'05
'06
Number of HFRS Cases in USFK
Personnel*, 1986 – 2005
Number of Reported Cases
16
14
14
12
9
10
8
6
5
6
9
6
4
4
2
0
2
0
0
4
1
2
1
2 2
#
0
4
3
0
0
'86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06
Year
* USFK includes US soldiers and KATUSAs; #One case during 2001 due to Seoul virus contracted at Yongsan Garrison
HFRS Patients by Area, 2005
KHF Patients by Area, ROK Military
KHF Patients by Area in ROK-2005
Inchonsi
Gyonggido
Gangwondo
Seoul
Chungbuk
Chungnam
Gyongbuk
Daejun
Junbuk
Gwangju
Daegu
Gyongnam
Junnam
Jeju
Busan
No. of patients
0
1 - 26
27 - 39
40 - 49
50 - 80
Rodents & Hantaviruses of Korea
Apodemus
agrarius
Figure 1. Apodemus
agrarius, the primary
reservoir of Hantaan virus
Rattus
norvegicus
Apodemus
peninsulae
Figure 2. Rattus
norvegicus, the primary
reservoir of Seoul virus
Figure 3. A. peninsulae,
primary reservoir of
Soochong virus
Rodent-borne disease surveillance at selected US
military training sites near the DMZ, 2000 - 2006
1
2
North Korea
1
1
South Korea
2
1
2
HFRS Risk
High Risk
Moderate Risk
Low Risk
1 HFRS Cases
Rodent-borne disease surveillance at
Dagmar North Training Area
A
B
C
D
(A) Overview of training site. (B) Rice paddies associated with tall grasses bordering training area. (C) Road leading
through a “tank trap” to the main training area (A). (D). Tall grassy intermittent stream bed.
Changing Seasons, FP-60
Spring
Early
EarlyFall
Fall
Early Summer
Winter
Habitat Modification, FP-60
Number of Small Mammals Captured
Near the DMZ, 2001 – 2005
Dagmar North
LTA 130
66
10
8
1
20
1
1
1
38
3
110
2
2
1722
`
Apodemus agrarius
Cricetulus triton
Microtus fortis
Rattus norvegicus
Eothenomys regulus
Crosidura lasiura
Micromys minutus
Mus musculus
Rattus rattus
`
6
6
4
2
3
12
59
4
`
Crosidura lasiura
Micromys minutus
Mus musculus
Rattus rattus
FP 60
1
21
313
Apodemus agrarius
Cricetulus triton
Microtus fortis
Rattus norvegicus
Eothenomys regulus
FP 10
1
1
3
1
2
`
493
Apodemus agrarius
Crosidura lasiura
Micromys minutus
Microtus fortis
Mus musculus
Rattus norvegicus
Apodemus agrarius
Cricetulus triton
Microtus fortis
Rattus norvegicus
Eothenomys regulus
695
Crosidura lasiura
Micromys minutus
Mus musculus
Rattus rattus
Table 1. Summary of patient histories for four patients that acquired HFRS infections while training at US and ROK operated
military training sites near the DMZ.
Patient
#1
#2
#3
#4
Onset of
Symptoms
5 Oct
3 Nov
6 Nov
12 Nov
Training
Dates
20-29 Sep
8-21 Oct
8-15 Oct
8-21 Oct
Training
Sites
LTA 320, 36, 37
FP 60
Twin Bridges
Rodriguez
Watkins
Twin Bridges
Twin Bridges
Rodriguez
Watkins
Incubation
Period
27 – 36 Days
26 – 39 Days
29 – 35 Days
35 – 48 Days
Virus
Match
FP 60
Twin Bridges
South
Twin Bridges
North
Twin Bridges
South
HTN/04-182 FP60
HTN/04-618 FP60
HTN/04-1293 FP60
HTN/04-1332 FP60
HTN/04-1282 FP60
HTN/04-1325 FP60
USFK patient #1
HTN/05-1459 TB
HTN/05-1465 TB
USFK patient #3
HTN/05-1410 TB
HTN/05-1411 TB
HTN/05-1437 TB
USFK patient #2
USFK patient #4
HTN/YJ89-13
HTN/05-1438 TB
60
HTN/05-1458 TB
HTN/05-1439 TB
HTN/04-1257 FP10
HTN/01-425 FP10
HTN/01-431 FP10
HTN/01-542FP10
HTN/02-185FP10
HTN/WC98-181
HTN/HC97-91
HTN/YC98-44
HTN/IJ97-100
76
HTN/HoJo
HTN/LEE
HTN/PC89-43
HTN/JH96-25
HTN/SN94-2
HTN/76-118
HTN/NS94-20
HTN/Jiang13 China
HTN/Bao9 China
HTN/AA1028 Russia
SOO/SOO-1
SOO/SOO-3
DOB
SEO/80-39
63
NJ Tree based on 281-bps nucleotides of G2M segment of HTNV from USFK HFRS patient
#1-4, 2005
100
100
100
100
89
FP60
TBTA-N
TBTA-S
FP10
0.01 substitutions/site
Figure 10. NJ Tree based on 281-bps nucleotides of the G2-M segment of the HTNV from USFK HFRS Patients 1-4, 2005.
Firing Point 60, Rodent
Habitat/Activities
Firing Point 60, Rodent
Habitat/Activities
Primary Rodent Trapping Lines
Patient # 3-05
Patients # 2-05
and # 4-05
Twin Bridges TA – Rodent Habitat
Rodent Foraging and
Migration
Virus Laden
Rodent Feces
Dirt Road Adjacent
to Fighting Positions
Fighting
Position
Potential
Infected
Dust
Virus Laden
Rodent Feces
Twin Bridges TA – Rodent Habitat
Rodent Activity
Dirt Road
Training Site
N
#
Cheorwon-gun
W
S
Hanta Virus Risk - 2005
FP 10
Yeoncheon-gun
Z
DM
FP 60
Chaparra l
LTA 130
MPR C
b
Pocheon-gun
Dagm ar North
Story R ange
C p C as t le
RISK CATEGORY
b
Warrior Base
b
b
b
C p G r eav e s
g in
Im
er
Ri v
b
Dongducheon-si
Monk ey 7
b
b
cp C AS EY
TB TA
C p H ov ey
b
VERY HIGH
HIGH
MODERATE
LOW
NOT DONE
C p G a ry O w e n
C p G ia nt
Paju-si
Yangju-gun
Gapyeong-gun
b
b
C p Es s ay o ns
b
C p H ow z e
b
C p R ed C lo ud
b
Uijeongbu-si
C p St an ley
Fig. 12. Dust created by wheeled vehicles along a dirt road and tracked vehicles at barren training
site associated with tall grass habitats.
Fig. 13. Wetting down dirt roads to reduce
dust.
Fig. 14. Discarding of refuse adjacent to
primary rodent habitat (tall grasses).
Dagmar North