Person-to-person transmission of severe fever with thrombocytopenia syndrome bunyavirus through blood contact

Severe fever with thrombocytopenia syndrome virus: a highly lethal bunyavirus

Severe fever with thrombocytopenia syndrome virus (SFTSV) is a novel bunyavirus. Since 2007, SFTS disease has been reported in China with high fatality rate up to 30%, which drew high attention from Centre for Disease Control and Prevention and government. SFTSV is endemic in the centra l and eastern China, Korea and Japan. There also have been similar cases reported in Vietnam. The number of SFTSV infection cases has a steady growth in these years. As SFTSV could transmitted from person to person, it will expose the public to infectious risk. In 2018 annual review of the Blueprint list of priority diseases, World Health Organisation has listed SFTSV infection as prioritised diseases for research and development in emergency contexts. However, the pathogenesis of SFTSV remains largely unclear. Currently, there are no specific therapeutics or vaccines to combat infections of SFTSV. This review discusses recent findings of epidemiology, transmission pathway, pathogenesis and treatments of SFTS disease.

Risk factors for person-to-person transmission of severe fever with thrombocytopenia syndrome

OBJECTIVE

To determine the risk factors for person-to-person transmission of severe fever with thrombocytopenia syndrome (SFTS).

DESIGN

Studies reporting the person-to-person transmission or cluster infection of SFTS were identified and included for risk-factor analyses.

METHODS

Risk factors were investigated by analyzing characteristics of index patients who caused cluster infection and correlation between exposure history and secondary infection.

RESULTS

Analyses of 23 clusters of SFTS infections indicated that all index patients died and that they all had a symptom of bleeding 24 hours before death. Of 89 secondary cases, 82% had been exposed to the index patients' blood. The blood-contact-specific secondary attack rate was 62.4% (73 of 117). The risk relative value was 25 (95% CI, 15-42); thus, the probability of a person getting infected was 25 times more likely when they had contacted blood than when they had not.

CONCLUSION

Exposure to blood of SFTS patients is the highest risk factor for person-to-person infection with SFTSV. SFTS patients' families and healthcare workers should be educated to handle SFTS patients properly and safely to prevent the spread of SFTSV.

Identification of recently identified tick-borne viruses (Dabieshan tick virus and SFTSV) by metagenomic analysis in ticks from Shandong Province, China

The aim of this study is to systematically examine the variety of viruses maintained in ticks from Shandong Province. A total of 2522 ticks were sampled from five cities of Shandong Province and divided into 264 pools according to location and species. Viral megagenomic analysis revealed the sequences of two viruses, Dabieshan tick virus and SFTSV. Then qRT-PCR and nested PCR were performed to confirm the presence of corresponding pathogens, which showed positive results for Dabieshan tick virus and SFTSV, with a minimum infection rate of 0.67% (17/2522) and 2.5% (63/2522), respectively. Phylogenetic analysis showed that Dabieshan tick virus formed a monophyletic cluster with the Yongjia tick virus and Uukuniemi virus from China, and SFTSV shared over 95% identity with human and animal derived isolates. These findings are the first time to demonstrate molecular evidence of Dabieshan tick virus in unrecognized endemic regions and indicate the need for further investigation.

Impact of C-Reactive Protein Levels on Differentiating of Severe Fever With Thrombocytopenia Syndrome From Japanese Spotted Fever

Background

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging viral hemorrhagic fever in China, Korea, and Japan. Japanese spotted fever (JSF), which belongs to spotted fever group rickettsioses, is also endemic to Western Japan. Patients with SFTS and those with JSF display many of the same clinical manifestations. Sudden fever, rash, tick bite, and neurological and gastrointestinal symptoms may be seen in both infections, but the frequency and severity of each disease have not been compared and studied. Because laboratory confirmation of pathogens takes time, it is important to predict diagnosis of SFTS vs JSF based on the features of the clinical characteristics at the initial presentation, particularly in primary care settings.

Methods

We conducted a case series review at 4 medical facilities in Miyazaki, Japan. Based on the medical records, clinical and laboratory characteristics were compared between patients with SFTS and those with JSF.

Results

Eighty-one patients were enrolled in this study, including 41 with SFTS and 40 with JSF. The absence of rash (P < .001), leukopenia (P < .001), and normal C-reactive protein (CRP) levels (P < .001) were the variables distinguishing SFTS from JSF. Normal CRP levels (≤1.0 mg/dL) had a 95% sensitivity (84%–99%) and 97% specificity (87%–100%) for SFTS, with a positive likelihood ratio of 37.1 (5.35–257).

Conclusions

Normal serum CRP levels were shown to differentiate SFTS from JSF with a very high probability.

Severe fever with thrombocytopenia syndrome virus: a systematic review and meta-analysis of transmission mode

Severe fever with thrombocytopenia syndrome (SFTS) is a disease with a high case-fatality rate that is caused by infection with the SFTS virus (SFTSV). Five electronic databases were systematically searched to identify relevant articles published from 1 January 2011 to 1 December 2019. The pooled rates with 95% confidence interval (CI) were calculated by a fixed-effect or random-effect model analysis. The results showed that 92 articles were included in this meta-analysis. For the confirmed SFTS cases, the case-fatality rate was 0.15 (95% CI 0.11, 0.18). Two hundred and ninety-six of 1384 SFTS patients indicated that they had been bitten by ticks and the biting rate was 0.21 (95% CI 0.16, 0.26). The overall pooled seroprevalence of SFTSV antibodies among the healthy population was 0.04 (95% CI 0.03, 0.05). For the overall seroprevalence of SFTSV in animals, the seroprevalence of SFTSV was 0.25 (95% CI 0.20, 0.29). The infection rate of SFTSV in ticks was 0.08 (95% CI 0.05, 0.11). In conclusion, ticks can serve as transmitting vectors of SFTSVs and reservoir hosts. Animals can be infected by tick bites, and as a reservoir host, SFTSV circulates continuously between animals and ticks in nature. Humans are infected by tick bites and direct contact with patient secretions.

A Model for the Production of Regulatory Grade Viral Hemorrhagic Fever Exposure Stocks: From Field Surveillance to Advanced Characterization of SFTSV

Severe fever with thrombocytopenia syndrome virus (SFTSV) is an emerging human pathogen, endemic in areas of China, Japan, and the Korea (KOR). It is primarily transmitted through infected ticks and can cause a severe hemorrhagic fever disease with case fatality rates as high as 30%. Despite its high virulence and increasing prevalence, molecular and functional studies in situ are scarce due to the limited availability of high-titer SFTSV exposure stocks. During the course of field virologic surveillance in 2017, we detected SFTSV in ticks and in a symptomatic soldier in a KOR Army training area. SFTSV was isolated from the ticks producing a high-titer viral exposure stock. Through the use of advanced genomic tools, we present here a complete, in-depth characterization of this viral stock, including a comparison with both the virus in its arthropod source and in the human case, and an in vivo study of its pathogenicity. Thanks to this detailed characterization, this SFTSV viral exposure stock constitutes a quality biological tool for the study of this viral agent and for the development of medical countermeasures, fulfilling the requirements of the main regulatory agencies.

A single-domain antibody inhibits SFTSV and mitigates virus-induced pathogenesis in vivo

Severe fever with thrombocytopenia syndrome virus (SFTSV) is a novel tick-borne bunyavirus that recently emerged in East Asian countries. SFTS is characterized by high fever, thrombocytopenia, leukopenia, multiorgan failure, and hemorrhage with case fatality rates of 6.3% to 30%. Neither antivirals nor vaccines are available at present. We previously demonstrated that neutralizing antibodies specific for SFTSV glycoprotein (Gn) played a vital role in the survival of patients with SFTS. Nanobodies from camels present unique properties, such as thermostability, high affinity, and low immunogenicity. In the current study, mammalian expressed SFTSV Gn was used to immunize a camel, and functional nanobodies were isolated from the B cell nanobody library constructed from the immunized animal. Clone SNB02 was selected for in-depth analysis for its inhibition of SFTSV replication both in vitro and in vivo. We showed that SNB02 potently inhibited SFTSV infection and prevented thrombocytopenia in a humanized mouse model and is a potential candidate for therapeutics.

Development of a real-time loop-mediated isothermal amplification method for the detection of severe fever with thrombocytopenia syndrome virus

Severe fever with thrombocytopenia syndrome (SFTS) is being reported annually in South Korea since its first detection there in 2010. The causal agent is a negative-strand RNA virus 80–100 nm in diameter. It causes fever, thrombocytopenia, leukocytopenia, gastrointestinal symptoms, and neural symptoms. The mortality rate of SFTS was 32.6% among 172 cases reported from 2012 to 2015 in South Korea. Thus, is necessary to develop an effective diagnostic method that selectively identifies the isolates circulating in South Korea. The real-time reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay is a simple, rapid, and sensitive approach for molecular diagnosis. Here, we designed novel primers for this assay and found that the technique had very high specificity, sensitivity, and efficiency. This real-time RT-LAMP approach using the novel primers developed herein can be applied for early diagnosis of SFTSV strains in South Korea to reduce the mortality rate of SFTS.

Epidemiological and genetic investigation of a cluster of cases of severe fever with thrombocytopenia syndrome bunyavirus

Background

To analyze and discuss the transmission route of a cluster of cases of severe fever with thrombocytopenia syndrome bunyavirus (SFTSV).

Method

We performed an epidemiological investigation and a genetic analysis of patients with severe fever with thrombocytopenia syndrome (SFTS) caused by SFTSV, their close contacts and the surrounding population.

Results

We found that all patients had contact with the blood of the first patient. The comparison of gene sequences in the three isolated SFTSV strains showed that the strains were closely related. Six close contacts and nine individuals in the surrounding population were positive for SFTSV IgM antibody.

Conclusion

We suspect that the cluster outbreak was transmitted via blood and that the natural reservoir host of SFTSV exists in the patients’ environment.

The Nonstructural Protein of Guertu Virus Disrupts Host Defenses by Blocking Antiviral Interferon Induction and Action

Guertu virus (GTV) is a potentially highly pathogenic bunyavirus newly isolated in China, which is genetically related to the severe fever with thrombocytopenia syndrome virus (SFTSV) and Heartland virus (HRTV), two other emerging life-threatening bunyaviruses. Previous studies suggested that SFTSV and HRTV antagonize the interferon (IFN) system by targeting antiviral signaling proteins in different ways. However, whether and how GTV counteracts the host innate immunity are unclear. Here, we found that GTV strongly inhibits both IFN induction and action through its nonstructural protein (NSs). Different from the NSs of SFTSV and HRTV, GTV NSs (G-NSs) induced the formation of two distinctive cytoplasmic structures, compact inclusion bodies (IBs) and extended filamentous structures (FSs). Protein interaction and colocalization analyses demonstrated that G-NSs interacts with TBK1 (TANK binding kinase-1, the pivotal kinase for IFN induction) and STAT2 (signal transducer and activator of transcription 2, the essential transcription factor for IFN action) and irreversibly sequesters the host proteins into the viral IBs and FSs. Consistently, G-NSs thus inhibited phosphorylation/activation and nuclear translocation of IFN-regulatory factor 3 (IRF3, the substrate of TBK1), diminishing the IFN induction. Furthermore, G-NSs sequestration of STAT2 blocked phosphorylation/activation and nuclear translocation of STAT2, disabling IFN action and host antiviral state establishment. Collectively, this study shows the robust subversion of the two phases of the IFN antiviral system by GTV and unravels the respective molecular mechanisms, exhibiting some notable differences from those employed by SFTSV and HRTV, providing insights into the virus-host interactions and pathogenesis, and probably also benefiting the prevention and treatment of the related infectious diseases in the future.

Investigation of Heartland Virus Disease Throughout the United States, 2013-2017

Background

Heartland virus (HRTV) was first described as a human pathogen in 2012. From 2013 to 2017, the Centers for Disease Control and Prevention (CDC) implemented a national protocol to evaluate patients for HRTV disease, better define its geographic distribution, epidemiology, and clinical characteristics, and develop diagnostic assays for this novel virus.

Methods

Individuals aged ≥12 years whose clinicians contacted state health departments or the CDC about testing for HRTV infections were screened for recent onset of fever with leukopenia and thrombocytopenia. A questionnaire was administered to collect data on demographics, risk factors, and signs and symptoms; blood samples were tested for the presence of HRTV RNA and neutralizing antibodies.

Results

Of 85 individuals enrolled and tested, 16 (19%) had evidence of acute HRTV infection, 1 (1%) had past infection, and 68 (80%) had no infection. Patients with acute HRTV disease were residents of 7 states, 12 (75%) were male, and the median age (range) was 71 (43-80) years. Illness onset occurred from April to September. The majority reported fatigue, anorexia, nausea, headache, confusion, arthralgia, or myalgia. Fourteen (88%) cases were hospitalized; 2 (13%) died. Fourteen (88%) participants reported finding a tick on themselves in the 2 weeks before illness onset. HRTV-infected individuals were significantly older (P < .001) and more likely to report an attached tick (P = .03) than uninfected individuals.

Conclusions

Health care providers should consider HRTV disease testing in patients with an acute febrile illness with either leukopenia or thrombocytopenia not explained by another condition or who were suspected to have a tickborne disease but did not improve following appropriate treatment.

Spatial-temporal characteristics of severe fever with thrombocytopenia syndrome and the relationship with meteorological factors from 2011 to 2018 in Zhejiang Province, China

BACKGROUND

Zhejiang Province has the fifth-highest incidence of severe fever with thrombocytopenia syndrome (SFTS) in China. While the top four provinces are all located in northern and central China, only Zhejiang Province is located in the Yangtze River Delta region of southeast China. This study was undertaken to identify the epidemiological characteristics of SFTS in Zhejiang from 2011 to 2018.

METHODS

The epidemic data from SFTS cases in Zhejiang Province from January 2011 to December 2018 were obtained from the China Information Network System of Disease Prevention and Control. Meteorological data were collected from the China Meteorological Data Sharing Service System. A multivariate time series model was used to analyze the heterogeneity of spatial-temporal transmission of the disease. Random forest analysis was performed to detect the importance of meteorological factors and the dose-response association of the incidence of SFTS with these factors.

RESULTS

In total, 412 SFTS cases (49 fatal) were reported from January 2011 to December 2018 in Zhejiang Province, China. The number of SFTS cases and the number of affected counties increased year by year. The case fatality rate in Zhejiang Province was 11.89%, which was the highest in China. Elderly patients and farmers were the most affected. The total effect values of the autoregressive component, spatiotemporal component and endemic component of the model in all ranges were 0.4580, 0.0377 and 0.0137, respectively. There was obvious heterogeneity across counties for the mean values of the spatiotemporal component and the autoregressive component. The autoregressive component was obviously the main factor driving the occurrence of SFTS, followed by the spatiotemporal component. The importance scores of the monthly mean pressure, mean temperature, mean relative humidity, mean two-minute wind speed, duration of sunshine and precipitation were 10.64, 8.34, 8.16, 6.37, 5.35 and 2.81, respectively. The relationship between these factors and the incidence of SFTS is complicated and nonlinear. A suitable range of meteorological factors for this disease was also detected.

CONCLUSIONS

The autoregressive and spatiotemporal components played an important role in driving the transmission of SFTS. Targeted preventive efforts should be made in different areas based on the main component contributing to the epidemic. For most areas, early measures several months ahead of the suitable season for the occurrence of SFTS should be implemented. The level of reporting and diagnosis of this disease should be further improved.

Clinical Score System to Differentiate Severe Fever with Thrombocytopenia Syndrome Patients from Patients with Scrub Typhus or Hemorrhagic Fever with Renal Syndrome in Korea

BACKGROUND

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease with high mortality in East Asia. This study aimed to develop, for primary care providers, a prediction score using initial symptoms and basic laboratory blood tests to differentiate between SFTS and other endemic zoonoses in Korea.

METHODS

Patients aged ≥ 18 years diagnosed with endemic zoonoses during a 3-year period (between January 2015 and December 2017) were retrospectively enrolled from 4 tertiary university hospitals. A prediction score was built based on multivariate logistic regression analyses.

RESULTS

Of 84 patients, 35 with SFTS and 49 with other endemic zoonoses were enrolled. In multivariate logistic regression analysis, independent predictors of SFTS included neurologic symptoms (odds ratio [OR], 12.915; 95% confidence interval [CI], 2.173-76.747), diarrhea (OR, 10.306; 95% CI, 1.588-66.895), leukopenia (< 4,000/mm³) (OR, 19.400; 95% CI, 3.290-114.408), and normal C-reactive protein (< 0.5 mg/dL) (OR, 24.739; 95% CI, 1.812-337.742). We set up a prediction score by assigning one point to each of these four predictors. A score of ≥ 2 had 82.9% sensitivity (95% CI, 71.7%-87.5%) and 95.9% specificity (95% CI, 88.0%-99.2%). The area under the curve of the clinical prediction score was 0.950 (95% CI, 0.903-0.997).

CONCLUSION

This study finding suggests a simple and useful scoring system to predict SFTS in patients with endemic zoonoses. We expect this strategic approach to facilitate early differentiation of SFTS from other endemic zoonoses, especially by primary care providers, and to improve the clinical outcomes.

Antiviral Drugs Against Severe Fever With Thrombocytopenia Syndrome Virus Infection

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging tick-borne infectious disease caused by SFTS virus (SFTSV), which is a novel bunyavirus. SFTSV was first isolated from patients who presented with fever, thrombocytopenia, leukocytopenia, and multiorgan dysfunction in China. Subsequently, it was found to be widely distributed in Southeast Asia (Korea, Japan, and Vietnam). SFTSV can be transmitted not only from ticks but also from domestic animals, companion animals, and humans. Because the case fatality rate of SFTS is high (6–30%), development of specific and effective treatment for SFTS is required. Studies of potential antiviral drugs for SFTS-specific therapy have been conducted on existing or newly discovered agents in vitro and in vivo, with ribavirin and favipiravir being the most promising candidates. While animal experiments and retrospective studies have demonstrated the limited efficacy of ribavirin, it was also speculated that ribavirin would be effective in patients with a viral load <1 × 10⁶ copies/mL. Favipiravir showed higher efficacy than ribavirin against SFTSV in in vitro assays and greater efficacy in animal models, even administrated 3 days after the virus inoculation. Although clinical trials evaluating the efficacy of favipiravir in SFTS patients in Japan are underway, this has yet to be confirmed. Other drugs, including hexachlorophene, calcium channel blockers, 2′-fluoro-2′-deoxycytidine, caffeic acid, amodiaquine, and interferons, have also been evaluated for their inhibitory efficacy against SFTSV. Among them, calcium channel blockers are promising because in addition to their efficacy in vitro and in vivo, retrospective clinical data have indicated that nifedipine, one of the calcium channel blockers, reduced the case fatality rate by >5-fold. Although further research is necessary to develop SFTS-specific therapy, considerable progress has been achieved in this area. Here we summarize and discuss recent advances in antiviral drugs against SFTSV.

Zwiesel bat banyangvirus, a potentially zoonotic Huaiyangshan banyangvirus (Formerly known as SFTS)-like banyangvirus in Northern bats from Germany

Bats are reservoir hosts for several emerging and re-emerging viral pathogens causing morbidity and mortality in wildlife, animal stocks and humans. Various viruses within the family Phenuiviridae have been detected in bats, including the highly pathogenic Rift Valley fever virus and Malsoor virus, a novel Banyangvirus with close genetic relation to Huaiyangshan banyangvirus (BHAV)(former known as Severe fever with thrombocytopenia syndrome virus, SFTSV) and Heartland virus (HRTV), both of which have caused severe disease with fatal casualties in humans. In this study we present the whole genome of a novel Banyangvirus, named Zwiesel bat banyangvirus, revealed through deep sequencing of the Eptesicus nilssonii bat virome. The detection of the novel bat banyangvirus, which is in close phylogenetic relationship with the pathogenic HRTV and BHAV, underlines the possible impact of emerging phenuiviruses on public health.

Emerging and re-emerging infectious diseases in Japan: epidemiology and infection prevention measures

In recent years, emerging and re-emerging infectious diseases, such as the Ebola virus disease and Middle East Respiratory Syndrome (MERS), have been frequently reported. In this review, we summarize the representative outbreaks of emerging and re-emerging infectious diseases since 2000 and outbreaks of various infectious diseases that have occurred around the world and in Japan. Moreover, the emerging and re-emerging infectious diseases that could develop in Japan are also summarized. Especially, for mosquito-borne infectious diseases, viral hemorrhagic fever and severe fever with thrombocytopenia syndrome, and avian Influenza and MERS, the disease features, routes of infection, and infection prevention measures are reviewed in this article. Healthcare workers are at high risk of infection, and therefore, a sufficient understanding of disease features and routes of infection and the appropriate infection prevention measures are needed to increase self-protection.

Cross-genotype protection of live-attenuated vaccine candidate for severe fever with thrombocytopenia syndrome virus in a ferret model

Severe fever with thrombocytopenia syndrome virus (SFTSV) is an emerging viral pathogen discovered in 2009. The virus is present in countries of East Asia and is transmitted through the bite of an infected Haemaphysalis longicornis tick. SFTSV disease is associated with high morbidity and is often fatal. Despite the incidence of disease, no antiviral therapy or vaccine has been approved for use. Here, we report and assess 2 live attenuated viruses as vaccine candidates in our recently described ferret model of infection. We show that the viruses caused no clinical disease or mortality in healthy animals. Immunized animals mounted a robust humoral immune response to a single dose of virus, and this response protected the animals from a lethal challenge.

Severe fever with thrombocytopenia syndrome (SFTS) virus (SFTSV) is an emerging tick-borne virus classified within the Banyangvirus genus. SFTS disease has been reported throughout East Asia since 2009 and is characterized by high fever, thrombocytopenia, and leukopenia and has a 12 to 30% case fatality rate. Due to the recent emergence of SFTSV, there has been little time to conduct research into preventative measures aimed at combatting the virus. SFTSV is listed as one of the World Health Organization’s Prioritized Pathogens for research into antiviral therapeutics and vaccine development. Here, we report 2 attenuated recombinant SFTS viruses that induce a humoral immune response in immunized ferrets and confer complete cross-genotype protection to lethal challenge. Animals infected with rHB29NSsP₁₀₂A or rHB2912aaNSs (both genotype D) had a reduced viral load in both serum and tissues and presented without high fever, thrombocytopenia, or mortality associated with infection. rHB29NSsP₁₀₂A- or rHB2912aaNSs-immunized animals developed a robust anti-SFTSV immune response against cross-genotype isolates of SFTSV. This immune response was capable of neutralizing live virus in a focus-reduction neutralization test (FRNT) and was 100% protective against a cross-genotype lethal challenge with the CB1/2014 strain of SFTSV (genotype B). Thus, using our midsized, aged ferret infection model, we demonstrate 2 live attenuated vaccine candidates against the emerging pathogen SFTSV.

Severe rhabdomyolysis associated with severe fever with thrombocytopenia syndrome in a married couple: a case report

Background

Severe fever with thrombocytopenia syndrome (SFTS) is a tick-borne infection that has recently emerged. This infectious disease is due to the transfer of SFTS virus (SFTSV) from the infected blood of animals to humans. Approximately 30% of patients who are infected with SFTS die from multiorgan failure associated with severe infection, systemic inflammatory response syndrome, or disseminated intravascular coagulation. We treated an elderly Japanese couple (husband and wife) who had genetically identical SFTSV infections and who both developed severe rhabdomyolysis.

Case presentation

An 80-year-old man presented to the clinic with a fever; his 74-year-old wife presented with a fever 9 days later. Their laboratory results at diagnosis showed severe rhabdomyolysis with significantly elevated creatinine kinase (detected levels: husband, 9546 U/L; wife, 15,933 U/L). The creatinine kinase isozyme was 100% MM type in both patients. In both the husband and wife, SFTSV was identified with real-time polymerase chain reaction analysis. The detected SFTSVs in both the husband and wife were identical according to the genome sequence analysis. The husband’s bone marrow indicated macrophage activation syndrome, but he responded to supportive therapy. He was discharged after being hospitalized for 32 days. The wife was admitted to our hospital in critical condition 2 days after SFTS symptom onset. She died of multiorgan failure 8 days after onset, despite being cared for in an intensive care unit. Both of the patients presented with rhabdomyolysis following SFTS symptom onset. The patients’ clinical outcomes were different from each other; i.e., the husband survived, and the wife died.

Conclusions

SFTSV infection-associated rhabdomyolysis has been reported in one patient, and simultaneous onset in two related patients has not been described previously. Our findings suggest that similar biological responses occurred, but they resulted in different clinical outcomes in the patients infected by the identical SFTSV isolates. Notably, a patient’s clinical outcome depends on their own immune response. We suggest that one component of viral rhabdomyolysis involves immune-mediated responses. Severe immunological responses may adversely affect the treatment outcome, as demonstrated by the wife’s clinical course. Our findings demonstrate that a patient’s immune response contributes to their prognosis following SFTSV infection.

Assessment of potential effects and detection efficacy of a fluorescent marking system on a medically important hard tick, Haemaphysalis longicornis (Acari: Ixodidae)

BACKGROUND

Although Haemaphysalis longicornis (Acari: Ixodidae) is an important disease vector, its small size restricts the tracking methods applicable. Recently, fluorescent marking as a conventional detection method for small arthropods has been improved by combining it with an ultraviolet laser. We examined the application potential of this new fluorescent marking system (FMS) for tracking H. longicornis by evaluating the effect of fluorescent marking on the ticks and detection efficacy.

RESULTS

Under laboratory conditions, fluorescent marking did not significantly affect the survivorship, movement patterns, and CO₂ response of H. longicornis at all three developmental stages. Fluorescent-marked individuals could be detected at distances ranging from 12 to 29 m under dark, increasing with the body size. Finally, in grassland, >90% of fluorescent-marked individuals were retrieved at night regardless of developmental stage. However, the overall detection rate (<42%) was substantially reduced during the day.

CONCLUSIOIN

Our results show that FMS can reliably detect H. longicornis at night. Nevertheless, fluorescent-marked individuals are not as conspicuous under sunlight when they are illuminated with ultraviolet lasers, limiting the use of FMS during the day. Therefore, the development of an alternative tracking method is warranted for an effective detection of ticks during the day. © 2019 Society of Chemical Industry.

Immune Modulation and Immune-Mediated Pathogenesis of Emerging Tickborne Banyangviruses

In the last decade, the emergence of several, novel tickborne viruses have caused significant disease in humans. Of interest are the tickborne banyangviruses: Severe fever with thrombocytopenia syndrome virus (SFTSV), Heartland virus (HRTV), and Guertu virus (GTV). SFTSV and HRTV infection in humans cause viral hemorrhagic fever-like disease leading to mortality rates ranging from 6–30% of the cases. The systemic inflammatory response syndrome (SIRS) associated with SFTSV infection is hypothesized to contribute significantly to pathology seen in patients. Despite the severe disease caused by HRTV and SFTSV, there are no approved therapeutics or vaccines. Investigation of the immune response during and following infection is critical to the generation of fully protective vaccines and/or supportive treatments, and overall understanding of viral immune evasion mechanisms may aid in the development of a new class of therapeutics.

Establishing China's national standards of antigen content and neutralizing antibody responses for evaluation of SFTS vaccines

Severe fever with thrombocytopenia syndrome (SFTS) is an acute infectious disease caused by severe fever with thrombocytopenia syndrome virus (SFTSV). SFTS is mainly characterized by severe fever with thrombocytopenia and has a high mortality rate. The virus has been found in China, South Korea, and Japan. Effective antiviral drugs or vaccines still have been unavailable. Now, two vaccine manufacturers in China are actively engaged in the development of the vaccine. To promote the development of SFTS vaccines and ensure their effective quality control, we developed national antigen and antibody references. We collaborative calibrated the standards; evaluated the homogeneity and stability of the national SFTS standards. The national SFTS vaccine antigen and antibody references met the Chinese national standards and can be used to standardize quality control for the manufacture of SFTS vaccines. And also can be used into the study the dose-response relationship of SFTS vaccines, determine clinical doses, and evaluate vaccine immunogenicity.

A Cluster of Bunyavirus-Associated Severe Fever With Thrombocytopenia Syndrome Cases in a Coastal Plain Area in China, 2015: Identification of a Previously Unidentified Endemic Region for Severe Fever With Thrombocytopenia Bunyavirus

Background

Severe fever with thrombocytopenia syndrome (SFTS) is a typical tick-borne, natural focal disease. The natural foci of SFTS were considered to exist in hilly and mountainous areas before 2015. A cluster of 3 patients exposed to a patient with a fulminant disease consistent with SFTS occurred from July to August 2015 in Dongtai County, which is characterized by alluvial plains; this prompted investigation.

Methods

The epidemiological, clinical, and laboratory features of 4 patients in the cluster were analyzed. Serum samples from the indigenous healthy population and native domesticated animals were collected to conduct laboratory tests, along with small wild animals and ticks.

Results

In 3 secondary case patients, high fever, thrombocytopenia and leukopenia developed within 8-13 days after contact with blood or bloody secretions from the index patient; SFTS was then diagnosed by means of reverse-transcription polymerase chain reaction. Genomic sequencing and analysis of S and L segments of 2 viral strains isolated from 2 secondary case patients showed that they shared 99.8%-99.9% homology in nucleotide sequence. The seroprevalences among indigenous healthy population, native livestock, native poultry, and small wild animals was 0.74%, 17.54%, 6.67%, and 1.12%, respectively. Three questing ticks, 61 feeding ticks, and 178 small wild animals were collected in August 2015. Survey on tick density and seasonal fluctuation in 2016 showed that ticks were active from March to October. All ticks were identified as Haemaphysalis longicornis. Severe fever with thrombocytopenia bunyavirus (SFTSV)-specific RNA was detected in the ticks collected in 2016, and the minimum SFTSV infection rate in these ticks was 0.54% (1 of 185).Wild mammals and ticks collected in August 2015 tested negative for SFTSV-specific RNA.

Conclusions

Aside from hilly or mountainous area, a coastal plain was identified as the natural foci of SFTSV in Dongtai County, China. The involvement of migration in the evolution of SFTSV might lead to a transregional transmission event of SFTSV.

Environmental Risk Factors and Geographic Distribution of Severe Fever with Thrombocytopenia Syndrome in Jiangsu Province, China

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging natural focus, tick-borne disease caused by a novel bunyavirus named SFTS virus (SFTSV). The main purpose of this study was to analyze the environmental risk factors and geographic distribution of SFTS natural foci in Jiangsu Province. A retrospective space-time analysis by SaTScan software was used to detect clusters at the town level. The maximum entropy modeling method was applied to construct the ecological niche model and analyze the environmental risk factors, and then to draw the predicted risk map. The performance of the model was assessed using the area under the curve (AUC) and known occurrence locations. During the years 2010-2016, a total of 140 laboratory-confirmed indigenous SFTS cases occurred in Jiangsu Province, with 66 occurrence locations. The reported number of SFTS cases increased year by year and SFTS cases occurred from April to October with a peak between May and August each year. Three clusters detected by space-time scan statistical analysis were connected together and shared the similar ecological environmental characteristic of hilly landscape. Fifteen environmental variables with different percent contribution can influence the ecological niche model in different degrees, whereas slope (suitable range: 0.1-4) and maximum temperature of warmest month (suitable range: 32.8-34.2°C) as the key environmental factors contributed 46.1% and 23.2%, respectively. The model had high accuracy on prediction with the averaged training AUC of 0.926. Within a predicted risk map, potential areas at high risk and 10 previously unidentified endemic regions were recognized. The distribution of SFTS natural foci was under the influence of multidimensional environmental factors. Slope and maximum temperature of warmest month were the key environmental risk factors. These results provide a valuable basis for the selection of prevention and control strategies, and the identification of potential risk areas.

Fulminant myocarditis associated with severe fever with thrombocytopenia syndrome: a case report

Background

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging viral infectious disease with high mortality. It causes multiple organ dysfunction; however, myocarditis has never been reported as a complication with SFTS.

Case presentation

A 62-year-old previously healthy woman developed fever, fatigue, diarrhea, and a mild consciousness disorder. She visited a local clinic, and laboratory data showed leukocytopenia, thrombocytopenia, and elevation of the aspartate aminotransferase level. She was transferred to Kagoshima University Hospital and diagnosed as having SFTS by real-time reverse transcription polymerase chain reaction. Subsequently, her blood pressure gradually decreased despite fluid resuscitation and vasopressor administration. Based on elevated toroponin I levels in serum, a transient diffuse left ventricular hypokinesis and wall thickening in echocardiography, diffuse ST elevation in electrocardiography, and exclusion of other heart diseases, she was diagnosed as having fulminant myocarditis. After hemodynamic support with inotropic agents, she recovered near normal cardiac function. She was discharged to home on day 28.

Conclusions

We report the first case of fulminant myocarditis associated with SFTS.

Seroprevalence of severe fever with thrombocytopenia syndrome virus antibodies among inhabitants of Dachen Island, eastern China

Severe fever with thrombocytopenia syndrome virus (SFTSV) has been emerging and has caused many human cases in China, Japan and Korea. Some studies speculated that SFTSV was transmitted with bird migration among these countries. Notably, SFTS cases have been identified in a Chinese island named Dachen which is situated southwest of Japan and Korea. In this study, we conducted a serum survey of SFTSV antibodies among inhabitants of the island. A total of 439 serum specimens were collected in June 2018. All serum samples were tested for total antibodies and IgM antibody with double-antigen sandwich ELISA method. The rates of seropositivity for SFTSV total antibodies and IgM antibody were 3.0% (95% CI 1.4-4.6) and 0.5% (2/439), respectively. The median age of all participants was 61 years and all seropositive samples were all from inhabitants aged >50 years. The differences of seroprevalence between different gender groups and different age groups were not significant. However, seroprevalence varied significantly among different villages (P = 0.033). Our results showed that some inhabitants of Dachen Island had been infected with SFTSV, and some ticks and host animals of the island carry SFTSV. Comprehensive measures should be conducted to prevent the occurrence of SFTS cases in the island.

An anti-Gn glycoprotein antibody from a convalescent patient potently inhibits the infection of severe fever with thrombocytopenia syndrome virus

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease localized to China, Japan, and Korea that is characterized by severe hemorrhage and a high fatality rate. Currently, no specific vaccine or treatment has been approved for this disease. To develop a therapeutic agent for SFTS, we isolated antibodies from a phage-displayed antibody library that was constructed from a patient who recovered from SFTS virus (SFTSV) infection. One antibody, designated as Ab10, was reactive to the Gn envelope glycoprotein of SFTSV and protected host cells and A129 mice from infection in both in vitro and in vivo experiments. Notably, Ab10 protected 80% of mice, even when injected 5 days after inoculation with a lethal dose of SFTSV. Using cross-linker assisted mass spectrometry and alanine scanning, we located the non-linear epitope of Ab10 on the Gn glycoprotein domain II and an unstructured stem region, suggesting that Ab10 may inhibit a conformational alteration that is critical for cell membrane fusion between the virus and host cell. Ab10 reacted to recombinant Gn glycoprotein in Gangwon/Korea/2012, HB28, and SD4 strains. Additionally, based on its epitope, we predict that Ab10 binds the Gn glycoprotein in 247 of 272 SFTSV isolates previously reported. Together, these data suggest that Ab10 has potential to be developed into a therapeutic agent that could protect against more than 90% of reported SFTSV isolates.

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease localized to China, Japan, and Korea. The tick-borne virus that causes SFTS has infected more than 5,000 humans, with a 6.4% to 20.9% fatality rate. Currently, there are no prophylactic or therapeutic measures against this virus. Historically, antibodies from patients who recovered from viral infection have been used to treat new patients, and commercially available antiviral monoclonal antibodies have been developed. Palivizumab was approved for the prophylaxis of respiratory syncytial virus (RSV) infection, and ibalizumab-uiyk was recently approved for the treatment of human immunodeficiency virus (HIV)-infected patients. To develop an antiviral monoclonal antibody for SFTS patients, we selected 10 antibodies from a patient who recovered from SFTS and found that one antibody potently inhibited SFTS viral infection both in vitro and in animal studies. We mapped the binding site of this antibody on the SFTS virus, which allowed us to predict that this antibody could bind 247 out of the 272 SFTS virus isolates reported to date. We anticipate that this antibody could be developed into a therapeutic treatment against SFTS.

Knowledge, Attitudes, and Practices regarding Severe Fever with Thrombocytopenia Syndrome in Endemic Areas of Anhui Province, Eastern China

This study aimed to assess baseline knowledge, attitudes, and practices about severe fever with thrombocytopenia syndrome (SFTS) and identify the target population for health education programs in endemic areas of Anhui, China. This cross-sectional study was conducted from May to June 2017. Of 752 participants, 383 (50.9%) were from Nanqiao District, 397 (52.8%) were female, and 430 (57.2%) were farmers; 37.4% had heard about SFTS, but knowledge of symptoms and signs including fever (34.2%), leukopenia (8.0%), and thrombocytopenia (10.1%) was low. Only 12.1% knew that SFTS virus is transmitted by ticks, 9.4% realized that the blood and body fluid of SFTS are infectious, and only 38.2% thought that the tick should be paralyzed using medical alcohol or iodine. Meanwhile, 61.3% wore long-sleeve clothes, whereas 20.2% used repellents. Median scores for knowledge, attitudes, and practices, and the total score were 4.0, 6.0, 5.0, and 16.0, respectively. Knowledge was influenced by region (OR = 0.632, 95% CI: 0.399-0.999), education (OR = 0.516, 95% CI: 0.434-0.612), gender (OR = 1.865, 95% CI: 1.165-2.987), and age (OR = 3.406, 95% CI: 2.345-4.947). Education was a predictor of lack of appreciation of infection risk (OR = 0.519, 95% CI: 0.449-0.599) and practice (OR = 0.481, 95% CI: 0.396-0.584). Our findings indicate that SFTS-related health education programs are required for females; participants from Qianshan Prefecture; those with an occupation of farmer, retiree, houseworker, or unemployed; elderly participants; and those with low education. Large-scale sustainable health education programs focusing on the target populations are urgently needed in endemic areas.

Aerosol transmission of severe fever with thrombocytopenia syndrome virus during resuscitation

We investigated potential nosocomial aerosol transmission of severe fever with thrombocytopenia syndrome virus (SFTSV) with droplet precautions. During aerosol generating procedures, SFTSV was be transmitted from person to person through aerosols. Thus, airborne precautions should be added to standard precautions to avoid direct contact and droplet transmission.

Identification of the first case of SFTSV infection in the Hunan Province of China and epidemiological surveillance in the locality

This study reports the etiological identification, clinical diagnosis, and the results of the local epidemiological surveillance of the first case of severe fever with thrombocytopenia syndrome virus (SFTSV) infection in 2014 in Hunan Province, China. The infected patient was isolated and closely monitored. The virus is a member of the Bunyaviridae sandfly family and is characterized by real-time PCR, electron microscopy, immunofluorescence, and whole-genome sequencing. We also detected IgG and IgM antibodies against SFTSV among the local human population and domestic animals in a serological surveillance. Prevalence of SFTSV-specific antibodies was monitored in the local population for two years after the identification of the first SFTS case. Approximately 5% (4/77) of the people who had direct contact with the patient were seropositive, which is significantly higher than the seropositivity of the general local population [1.57% (44/2800), P < 0.05]. Furthermore, the percentage of the general population who were seropositive was higher in 2015 than in 2014 (χ2 = 7.481, P = 0.006). The epidemiological investigation found that the SFTSV is epidemic in goats, cattle, and chickens in Hunan Province. The risk of infection of domestic animals can be minimized by feeding in pens rather than allowing foraging.

Neutralizing antibodies to Severe Fever with Thrombocytopenia Syndrome Virus in general population, Shandong Province, China

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease caused by SFTS virus (SFTSV) in East Asia. The research on seroprevalence of SFTSV in healthy people and risk factors had been detailed. However, the levels of neutralizing antibodies against SFTSV in general population were currently unclear. In the present study, we tested 1375 healthy persons from Penglai County, eastern China, for SFTSV neutralizing antibodies; 0.58% (8/1,375) was positive and the positive rates were not significantly different among people at different age groups, occupations and genders. Besides, a follow-up study was conducted and the titer of neutralizing antibodies decreased over time in all eight people but one, and the neutralizing antibodies of five lasted for the entire study period of seven years. Our results suggesting that subclinical infection or a relatively mild form of SFTS illness is occurring in this population, but a small percentage of sera have neutralizing capacity to SFTSV. Hence, most people are just susceptible to SFTSV infection.

Heartland Virus Epidemiology, Vector Association, and Disease Potential

First identified in two Missouri farmers exhibiting low white-blood-cell and platelet counts in 2009, Heartland virus (HRTV) is genetically closely related to severe fever with thrombocytopenia syndrome virus (SFTSV), a tick-borne phlebovirus producing similar symptoms in China, Korea, and Japan. Field isolations of HRTV from several life stages of unfed, host-seeking Amblyomma americanum, the lone star tick, implicated it as a putative vector capable of transstadial transmission. Laboratory vector competence assessments confirmed transstadial transmission of HRTV, demonstrated vertical infection, and showed co-feeding infection between A. americanum. A vertical infection rate of 33% from adult females to larvae in the laboratory was observed, while only one of 386 pools of molted nymphs (1930) reared from co-feeding larvae was positive for HRTV (maximum-likelihood estimate of infection rate = 0.52/1000). Over 35 human HRTV cases, all within the distribution range of A. americanum, have been documented. Serological testing of wildlife in areas near the index human cases, as well as in widely separated regions of the eastern United States where A. americanum occur, indicated many potential hosts such as raccoons and white-tailed deer. Attempts, however, to experimentally infect mice, rabbits, hamsters, chickens, raccoons, goats, and deer failed to produce detectable viremia. Immune-compromised mice and hamsters are the only susceptible models. Vertical infection augmented by co-feeding transmission could play a role in maintaining the virus in nature. A more complete assessment of the natural transmission cycle of HRTV coupled with serosurveys and enhanced HRTV disease surveillance are needed to better understand transmission dynamics and human health risks.

A cluster of cases of severe fever with thrombocytopenia syndrome bunyavirus infection in China, 1996: A retrospective serological study

BACKGROUND

A cluster of eleven patients, including eight family members and three healthcare workers with fever and thrombocytopenia occurred in Yixing County, Jiangsu Province, China, from October to November 1996. However, the initial investigation failed to identify its etiology. Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease caused by SFTS bunyavirus (SFTSV), which was first discovered in 2009. The discovery of novel SFTSV resulted in our consideration to test SFTSV on the remaining samples of this cluster in September 2010.

METHODOLOGY/PRINCIPAL FINDINGS

We retrospectively analyzed the epidemiological and clinical data of this cluster. The first case, one 55-year-old man with fulminant hemorrhagic diseases, died on October 14, 1996. His younger brother (the second case) developed similar hemorrhagic diseases after nursing him and then died on November 3. From November 4 to November 15, nine other patients, including six family members and three medical staffs, developed fever and thrombocytopenia after exposure to the second case. The sera of six patients were collected on November 24, 1996. IgM antibodies against SFTSV were detected in all of the six patients' sera using enzyme-linked immunosorbent assay (ELISA), while IgG antibodies were detected in one patient's serum using an indirect immunofluorescence assay (IFA). We also found that IgG antibodies against SFTSV were still detected in four surviving patients' sera 14 years after illness onset.

CONCLUSIONS AND SIGNIFICANCE

The mysterious pathogen of the cluster in 1996 was proved to be SFTSV on the basis of its epidemiological data, clinical data and serological results. It suggests that SFTSV has been circulating in China for more than 10 years before being identified in 2009, and SFTSV IgG antibodies can persist for up to 14 years.

Nonstructural protein of severe fever with thrombocytopenia syndrome phlebovirus targets STAT2 and not STAT1 to inhibit type I interferon-stimulated JAK-STAT signaling

The nonstructural protein NSs of severe fever with thrombocytopenia syndrome phlebovirus blocks type I interferon (IFN)-stimulated JAK-STAT signaling. However, there is continuing controversy as to whether NSs targets STAT1 or STAT2 or both for this blockade. The present study was designed to gain a further understanding of the blockade mechanism. Immunoprecipitation experiments revealed a stronger interaction of NSs with STAT2 than with any other component constituting the JAK-STAT pathway. Expression of NSs resulted in the formation of cytoplasmic inclusion bodies (IBs), and affected cytoplasmic distribution of STAT2. STAT2 was relocated to NSs-induced IBs. Consequently, NSs inhibited IFN-α-stimulated tyrosine phosphorylation and nuclear translocation of STAT2. These inhibitory effects as well as the signaling blockade activity were not observed in NSs mutant proteins lacking the STAT2-binding ability. In contrast, NSs affected neither subcellular distribution nor phosphorylation of STAT1 in response to IFN-α and IFN-γ, demonstrating that NSs has little physical and functional interactions with STAT1. Taken together, these results suggest that NSs sequesters STAT2 into NSs-induced IBs, thereby blocking type I IFN JAK-STAT signaling.

Correlations between clinical features and death in patients with severe fever with thrombocytopenia syndrome

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging high-fatality infectious disease caused by a novel phlebovirus belonging to the Bunyaviridae family. Thus, the independent predictors of death in this disease must be identified to improve the survival of affected patients.A total of 25 hospitalized patients with SFTS virus infection were enrolled in our study, and their medical records and laboratory data were reviewed. The risk factors for death were examined by binary logistic regression.The patient age was significantly higher in the deceased cases than in those who recovered (P = .020). Moreover, the occurrence of shock, respiratory failure, hemorrhagic manifestations, kidney dysfunction, and arrhythmia was significantly more common in the deceased cases than in the recovered cases (P = .016, P = .004, P = .005, P = .002, P = .038). Univariate binary logistic regression showed that shock, arrhythmia, and hemorrhage, as well as PCT, serum creatinine (Scr), and blood urea nitrogen (BUN) elevations, were the risk factors for death (odds ratio, OR 28.5, P = .015; OR 13.5, P = .027; OR 36, P = .008; OR 28.5, P = .015; OR 36, P = .008; and OR 76.0, P = .004). However, the BUN increase was the only independent risk factor for death indicated by multivariate logistic regression (OR 76.0, P = .004).SFTS presents with a high fatality rate. When patients with SFTS manifest shock, arrhythmia, hemorrhage, PCT increase, and Scr and BUN elevations, especially BUN > 8.2 μmol/L, health care providers should be alerted and must administer early intervention to prevent the progress to death.

Forecast of severe fever with thrombocytopenia syndrome incidence with meteorological factors

Severe fever with thrombocytopenia syndrome (SFTS) is emerging and some studies reported that SFTS incidence was associated with meteorological factors, while no report on SFTS forecast models was reported up to date. In this study, we constructed and compared three forecast models using autoregressive integrated moving average (ARIMA) model, negative binomial regression model (NBM), and quasi-Poisson generalized additive model (GAM). The dataset from 2011 to 2015 were used for model construction and the dataset in 2016 were used for external validity assessment. All the three models fitted the SFTS cases reasonably well during the training process and forecast process, while the NBM model forecasted better than other two models. Moreover, we demonstrated that temperature and relative humidity played key roles in explaining the temporal dynamics of SFTS occurrence. Our study contributes to better understanding of SFTS dynamics and provides predictive tools for the control and prevention of SFTS.

Current status of Severe Fever with Thrombocytopenia Syndrome vaccine development

Severe Fever with Thrombocytopenia Syndrome (SFTS) is a new emerging tick-borne disease caused by the phlebovirus, SFTS virus (SFTSV). The virus was discovered in central China in 2009 and has since been identified in both Japan and South Korea. Significant progress has been made on the molecular biology of the virus, and this has been used to develop diagnostic assays and reagents. Less progress has been made on the epidemiology, maintenance and transmission, clinical manifestations, immunological responses, and treatment regimens. A number of animal models have been investigated but, to date, none recapitulate all the clinical manifestations seen in humans. Vaccine development is at an early discovery phase.

Spatiotemporal patterns of severe fever with thrombocytopenia syndrome in China, 2011-2016

Severe fever with thrombocytopenia syndrome (SFTS) is emerging and the number of SFTS cases have increased year by year in China. However, spatiotemporal patterns and trends of SFTS are less clear up to date. In order to explore spatiotemporal patterns and predict SFTS incidences, we analyzed temporal trends of SFTS using autoregressive integrated moving average (ARIMA) model, spatial patterns, and spatiotemporal clusters of SFTS cases at the county level based on SFTS data in China during 2011-2016. We determined the optimal time series model was ARIMA (2, 0, 1) × (0, 0, 1)₁₂ which fitted the SFTS cases reasonably well during the training process and forecast process. In the spatial clustering analysis, the global autocorrelation suggested that SFTS cases were not of random distribution. Local spatial autocorrelation analysis of SFTS identified foci mainly concentrated in Hubei Province, Henan Province, Anhui Province, Shandong Province, Liaoning Province, and Zhejiang Province. A most likely cluster including 21 counties in Henan Province and Hubei Province was observed in the central region of China from April 2015 to August 2016. Our results will provide a sound evidence base for future prevention and control programs of SFTS such as allocation of the health resources, surveillance in high-risk regions, health education, improvement of diagnosis and so on.

Association between Severe Fever with Thrombocytopenia Syndrome Incidence and Ambient Temperature

Severe fever with thrombocytopenia syndrome (SFTS) is emerging in China. To explore the lagged effects and nonlinear association between temperature and SFTS, we collected data on ambient temperature and SFTS cases and analyzed the data using a distributed lag nonlinear model. A total of 1,933 SFTS cases were reported in the study area from 2011 to 2015. Our study revealed a nonlinear relationship between weekly temperature and SFTS. The exposure-response curve was an approximately reversed U-shaped peak at 23°C. High temperatures had acute and short-term effects, whereas low temperatures had persistent and long-term effects. The effects of lower temperatures (1.62°C and 6.97°C) could last 24 weeks, but the effect of 29.30°C was not significant at lag 8 weeks. Our results provide information to better understand the effect of temperature variation on SFTS and may have policy implications for disease prevention and control.

Characterization of clinical features and outcome for human-to-human transmitted severe fever with thrombocytopenia syndrome

BACKGROUND

Severe fever with thrombocytopenia syndrome (SFTS) is a life-threatening infectious disease identified in 2009. SFTS is mainly transmitted by contact with ticks or animals; however, sporadic reports suggested that SFTS could be transmitted among humans.

OBJECTIVES

We aimed to comprehensively characterize clinical features and disease progression of SFTS acquired by human-to-human transmission.

STUDY DESIGN

A retrospective study of 90 SFTS patients was performed in a tertiary hospital of Nanjing, China, from October 2010 to October 2016. Seven cases of secondary SFTS were identified based on their epidemic timeline. Their clinical presentations, dynamic laboratory results and clinical outcome were analyzed.

RESULTS

First, 20 out of 83 primary SFTS patients were deceased, leading to a case-fatality ratio of 24.1%, while all secondary patients survived, suggesting a superior clinical outcome for secondary infection. Moreover, clinical symptoms and laboratory tests in primary and secondary SFTS patients were analyzed, respectively. Secondary SFTS patients developed milder clinical manifestation in the absence of neurological disorder and multiple organ failure. Further, clinical laboratory tests revealed that secondary patients had less disturbed key laboratory parameters, compared to those in primary SFTS patients. During day 7-13 post illness onset, most of the clinical laboratory results of secondary patients went back to normal range. They also had significantly lower level of viral load than primary patients.

CONCLUSIONS

Secondary SFTS acquired through human-to-human transmission leads to milder clinical representations and superior prognoses compared to primary SFTS, suggesting that the transmission route makes a difference in disease progression and clinical outcome of SFTS disease.

Estimation of the incidence of severe fever with thrombocytopenia syndrome in high endemic areas in China: an inpatient-based retrospective study

BACKGROUND

Severe fever with thrombocytopenia syndrome (SFTS) is a severe viral disease caused by SFTSV. It is important to estimate the rate of missed SFTS diagnosis and to further understand the actual incidence in high endemic areas in China.

METHODS

This study was conducted in two high SFTS endemic provinces in 2015. Patients hospitalized in 2014 or within 1 year before investigation were selected after considering their clinical manifestations, specifically, fever, platelet, and white blood cell. During retrospective investigation, sera were collected to detect SFTSV antibodies to assess SFTSV infection. To further understand SFTSV infection, acute phase sera were detected; SFTSV infection rate among a healthy population was also investigated to determine the basic infection level.

RESULTS

In total, 246 hospitalized cases were included, including 83 cases (33.7%) with fever, thrombocytopenia and leukopenia, 38 cases (15.4%) with fever and thrombocytopenia but without leukopenia, and 125 cases (50.8%) without fever but with thrombocytopenia and leukopenia. In total, 13 patients (5.3%) were SFTSV IgM antibody-positive, 48 (19.5%) were IgG-positive. Of the 13 IgM-positive cases, 11 (84.6%) were IgG-positive (9 with titres ≥1:400). Seropositive rates of antibodies were high (8.4% for IgM and 30.1% for IgG) in patients with fever, thrombocytopenia and leukopenia. Furthermore, among IgG-positive cases in this group, 76% (19/25) of patients' IgG antibody titres were ≥1:400. Additionally, 28 of 246 cases were initially diagnosed with suspected SFTS and were then excluded, and 218 patients were never diagnosed with SFTS; the seropositive rates of IgM and IgG in these two groups were 25% and 67.9% and 2.8% and 13.3%, respectively. These rates were 64.3% and 21.4% in 14 sera collected during acute phase of the 28 cases mentioned above. Seropositive rate of SFTSV IgG was only 1.3% in the patient-matched healthy group, and no IgM antibody was detected. A preliminary estimate of 8.3% of SFTS cases were missed in SFTS high endemic provinces.

CONCLUSIONS

The actual SFTS incidence was underestimated. Effective measures such as adding a new SFTS case category - "SFTS clinical diagnosis cases" or using serological detection methods during acute phase should be considered to avoid missed diagnoses.

Accuracy of Diagnosis of Human Granulocytic Anaplasmosis in China

In 2008, human granulocytic anaplasmosis (HGA) was reported from China. However, the clinical and laboratory findings, including reports of nosocomial transmission, were inconsistent with those reported for HGA in the United States. In 2012, it was demonstrated that the patients described in the 2008 report had all been infected with a newly discovered bunyavirus, severe fever with thrombocytopenia syndrome virus, which causes an illness with the same clinical features described for the patients in the 2008 report. This finding raises the question of HGA misdiagnosis in China and establishes the need for further studies to determine whether HGA occurs there.

Investigation of antibody to severe fever with thrombocytopenia syndrome virus (SFTSV) in blood samples donated in a SFTS-endemic area in Japan

The risk of transfusion-transmitted infection (TTI) for severe fever with thrombocytopenia syndrome virus (SFTSV) is a concern because person-to-person transmission resulting from contact with SFTSV-contaminated blood has been reported. To obtain information regarding the risk of TTI-SFTSV, antibody testing was performed for blood samples donated in an severe fever with thrombocytopenia syndrome-endemic area in Japan. No antibody-positive samples were detected among 3990 samples. This finding suggested that there were few cases of SFTSV infection among donors and that the risk of TTI-SFTSV was also estimated low in Japan.

Severe Fever with Thrombocytopenia Syndrome in Patients Suspected of Having Scrub Typhus

To determine prevalence of severe fever with thrombocytopenia syndrome in South Korea, we examined serum samples from patients with fever and insect bite history in scrub typhus-endemic areas. During the 2013 scrub typhus season, prevalence of this syndrome among patients suspected of having scrub typhus was high (23.0%), suggesting possible co-infection.

Replication capacity and adaptability of a severe fever with thrombocytopenia syndrome virus at different temperatures

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging disease caused by the SFTS virus (SFTSV). Although fever and thrombocytopenia are the typical manifestations of SFTS, a specific SFTS case with no fever was observed in Zhejiang, China. In this report, we aimed to explore the probable reason for the absence of fever by analyzing the genetic characteristics and temperature sensitivity (ts) of the SFTSV strain ZJ2013-06, which was isolated from the specific case. Phylogenetically, different clusters of SFTSV strains circulated in Zhejiang. ZJ2013-06 was farthest from ZJ2014-02, an isolate belonging to a Chinese dominant cluster, and nearest to the coastal strain NB24/CHN/2013. Ts tests, performed on Vero cells at 37°C and 39°C, indicated that ZJ2013-06 had restricted replication at 39°C. Its viral loads were substantially reduced at 39°C compared with that at 37°C (approximately 100-fold reduction) and were significantly lower than that of ZJ2014-02 at 39°C (P < 0.01). By adaptive culture at 39°C, the induced strain ZJ2013-06-P7 was obtained. Owing to a reverse mutation (S1616), ZJ2013-06-P7 lost the ts of the original strain, displaying similar replication processes with NB24/CHN/2013. The results indicated that the amino acid residue 1616 was related to the ts characteristics of ZJ2013-06. Our study revealed that ZJ2013-06 was temperature-sensitive and may be related to the absence of fever in our case.

Molecular genomic characterization of tick- and human-derived severe fever with thrombocytopenia syndrome virus isolates from South Korea

BACKGROUND

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging tick-borne viral disease caused by the SFTS virus (SFTSV) from Bunyaviridae that is endemic in East Asia. However, the genetic and evolutionary characteristics shared between tick- and human-derived Korean SFTSV strains are still limited.

METHODOLOGY/PRINCIPAL FINDINGS

In this study we identify, for the first time, the genome sequence of a tick (Haemaphysalis longicornis)-derived Korean SFTSV strain (designated as KAGWT) and compare this virus with recent human SFTSV isolates to identify the genetic variations and relationships among SFTSV strains. The genome of the KAGWT strain is consistent with the described genome of other members of the genus Phlebovirus with 6,368 nucleotides (nt), 3,378 nt, and 1,746 nt in the Large (L), Medium (M) and Small (S) segments, respectively. Compared with other completely sequenced human-derived Korean SFTSV strains, the KAGWT strain had highest sequence identities at the nucleotide and deduced amino acid level in each segment with the KAGWH3 strain which was isolated from SFTS patient within the same region, although there is one unique amino acid substitution in the Gn protein (A66S). Phylogenetic analyses of complete genome sequences revealed that at least four different genotypes of SFTSV are co-circulating in South Korea, and that the tick- and human-derived Korean SFTSV strains (genotype B) are closely related to one another. Although we could not detect reassortant, which are commonly observed in segmented viruses, further large-scale surveillance and detailed genomic analysis studies are needed to better understand the molecular epidemiology, genetic diversity, and evolution of SFTSV.

CONCLUSIONS/SIGNIFICANCE

Full-length sequence analysis revealed a clear association between the genetic origins of tick- and human-derived SFTSV strains. While the most prevalent Korean SFTSV is genotype B, at least four different genotypes of SFTSV strains are co-circulating in South Korea. These findings provide information regarding the molecular epidemiology, genetic diversity, and evolution of SFTSV in East Asia.

Two confirmed cases of severe fever with thrombocytopenia syndrome with pneumonia: implication for a family cluster in East China

Background

Severe fever with thrombocytopenia syndrome (SFTS) was first reported in China in 2011. Human-to-human transmission of the virus occurred occasionally in family clusters. However, pneumonia as an onset syndrome was not common in most SFTS cases. Our aim is to report a family cluster of SFTS with clinical manifestation of pneumonia in Shanghai.

Methods

Epidemiologic investigations were conducted when a family cluster of severe fever with thrombocytopenia syndrome virus (SFTSV) infection was identified in Shanghai in June 2016. Samples were collected from two secondary cases and two close contacts with fever. SFTSV was detected by Real-Time reverse transcription polymerase chain reaction (RT-PCR).

Results

There were two confirmed STFS cases and one potential index case. The potential index case became ill on 21 May and died on 31 May. Case A had onset from 4 to 23 June and case B from 8 June to 25 June. All the three cases experienced pneumonia at the early stage of SFTSV infection. Three (3) out of thirty two (32) close contacts had symptoms of fever or cough but were detected STFSV negative by real-time RT-PCR. According to epidemiologic investigations, the potential index case had outdoor activities on a nearby hill. A tick bite could have been the reason for the SFTSV infection in the potential index case as ticks were found both in grassland or shrubs on the hill and also found on mice caught in her house. Both cases A and B had provided bedside care for the potential index case without any protection and had contacted with blood and other body fluids.

Conclusion

It was a family cluster of SFTSV infection imported from Jiangsu province located in the east of China. We suggested to become alert to atypical SFTSV infected cases.

A Cluster of Symptomatic and Asymptomatic Infections of Severe Fever with Thrombocytopenia Syndrome Caused by Person-to-Person Transmission

Severe fever with thrombocytopenia syndrome virus (SFTSV) is a novel phlebovirus that was identified to be the etiological pathogen of the emerging infectious disease, severe fever with thrombocytopenia syndrome (SFTS). SFTSV could be transmitted through tick bite. Transmission of SFTSV among humans has also been reported mainly through direct blood contact. In July 2014, a cluster of six suspected SFTS cases occurred in Shandong Province, China. In this cluster, both symptomatic and asymptomatic persons were included. By analyzing the clinical data and results of laboratory tests, and conducting the epidemiological interviews with the cases and their families, risk factors responsible for the transmission were evaluated. The findings suggested that SFTSV transmission among humans may cause asymptomatic infection via personal contact without blood exposure.

Risk factors associated with fatality of severe fever with thrombocytopenia syndrome: a meta-analysis

Severe fever with thrombocytopenia syndrome is an emerging life-threatening infectious disease identified in 2009. Given high case-fatality rate among patients with severe fever with thrombocytopenia syndrome, identification of the risk factors at acute phase associated with fatality is crucial for treatment. Therefore, we aimed to meta-analytically evaluate risk factors of fatal clinical outcome of severe fever with thrombocytopenia syndrome. 238 fatal cases and 873 non-fatal cases from 12 studies were included in this meta-analysis. Elder age and high viral load were significantly associated with fatal clinical outcome. Further, severe fever with thrombocytopenia syndrome patients with fatal clinical outcome had significantly reduced level of albumin and platelet count, higher level of serum alanine aminotransferase, aspirate aminotransferase, lactic acid dehydrogenase and creatinine phosphokinase, and prolonged activated partial thromboplastin time, comparing with mild patients. These disturbed parameters function as predictors to warn fatal clinical outcome of the disease. Moreover, ribavirin has a minimal impact to alleviate disease progression of severe fever with thrombocytopenia syndrome. In conclusion, our finding demonstrates a panel of factors associated with fatality of SFTS disease, which have important implications during clinical practice.