Spatial and Temporal Epidemiology of Nephropathia Epidemica Incidence and Hantavirus Seroprevalence in Rodent Hosts: Identification of the Main Environmental Factors in Europe

Puumala orthohantavirus circulation in its wild reservoir, the bank vole, during the 2021 outbreak of hemorrhagic fever with renal syndrome in Jura, France

OBJECTIVE

A large and unprecedented outbreak of an attenuated form of hemorrhagic fever with renal syndrome called nephropathia epidemica (NE) and caused by Puumala virus (PUUV) occurred in 2021 in the southern Jura Mountains (France) leading to numerous hospitalizations. The aim of this study was to investigate the circulation of PUUV in its animal reservoir at the time of this outbreak.

METHODS

We conjointly surveyed bank vole relative abundance, small mammal community composition, and PUUV circulation in bank voles (seroprevalence and genetic diversity) in the Jura NE epidemic area, between 2020 and 2022.

RESULTS

Trapping results showed a higher relative abundance of bank voles in 2021 compared to 2020 and 2022. Extremely high levels of PUUV seroprevalence in bank voles were found at the time of the human NE epidemic with seropositive animals trapped in almost all trap lines as of spring 2021. Genetic analyses of PUUV (S segment) gathered in 2021 at two sampling sites revealed a strong clustering of these strains within the "Jura" clade. No significant genetic variation was detected compared to what was already known to be circulating in the Jura region.

CONCLUSION

These results underline a need for enhanced monitoring of PUUV circulation in host reservoir populations in NE endemic areas. This would enable the relevant actors to better inform and sensitize the public on this zoonotic risk, and to implement prevention strategies in collaboration with physicians.

Epidemiology and Clinical Course of Haemorrhagic Fever with Renal Syndrome in New Endemic Area for Hantavirus Infection in Croatia

BACKGROUND

Hantaviruses remain an important case of emerging and re-emerging infections in human medicine. This study aimed to analyse the epidemiology, clinical presentation, and outcome of hantavirus infections in the western part of Republic of Croatia, a new geographical area for hantavirus infections.

METHODS

Retrospective analysis of medical records of patients treated for hemorrhagic fever with renal syndrome (HFRS) at the infectious diseases Clinic of the Clinical Hospital Center in Rijeka, Croatia, from 1 January 2014, to 31 December 2021.

RESULTS

During the eight-year period, 251 patients were hospitalized and treated for HFRS, with epidemic outbreaks in years 2014 and 2021. Most patients had a typical clinical course of HFRS and received supportive care. Serological analysis revealed the Puumala Virus (PUUV) as the predominant etiology of the disease. Epidemiological analysis revealed clustering of infections in the region of Gorski Kotar and spread to the area on the Mediterranean coast (Adriatic Sea), which was previously considered an area free from hantavirus infections.

CONCLUSIONS

The presented results indicate the spread of hantavirus infections in Croatia from the central low-lying parts of the country to the tourist-attractive western area adjacent to the Mediterranean coast, which was previously considered free of hantavirus infections.

Genetic and hosts characterization of hantaviruses in port areas in Hainan Province, P. R. China

BACKGROUND

Hantaviruses (HVs) are major zoonotic pathogens in China that cause hemorrhagic fever with renal syndrome (HFRS) posing a major threat to people's health. Hainan Province, an island located in Southeast China, is an ideal region for sea ports. The unique tropical monsoon climate in Hainan provides sufficient living conditions for rodents, which help spread HVs and other rodent-borne diseases. In the routine monitoring of hantavirus, there was no evidence that rodents in Hainan carried hantavirus. No patients infected with hantavirus were found in the past. However, the surveillance of HVs-carrying rodents covering the whole territory of Hainan has not stopped.

METHODOLOGY/PRINCIPAL FINDINGS

For the monitoring of the prevalence of HVs in rodents and the search for theoretical reference for rodent control and HFRS prevention, a total of 60 rodents from 6 monitoring spots were trapped around main ports in Hainan between 2016 and 2019. HV positive samples were identified by a specific kit and sequenced. The data indicated that seven rodents (Rattus norvegicus) were positive for hantavirus with a positivity rate of 11.67%. Phylogenetic analysis suggested that the two complete sequence strains HN1 and HN4 in this research were highly similar to the sequence strains GZRn36 and GZRn148 isolated in Guangdong Province, and they located in the same phylogenetic tree branch which belongs to S2 subtype. Although the two partial sequences HT1 and HT2 isolated in Xisha Islands belong to S2 subtype according to the phylogenetic tree of L segment, they showed a great nucleotide difference with HN1 and HN4. We also found 13 amino acid variations compared with SEOV 80-39 and 6 amino acid mutations related to epitope, and the variations may reduce the effectiveness of the current HFRS vaccines used in humans.

CONCLUSIONS/SIGNIFICANCE

The study indicated HVs carried by rodents found in Hainan Province may be transmitted from Guangdong Province through trading ports and carriage of goods by sea. So it is of great significance to strengthen the surveillance of rodents in port areas especially capture and eliminate rodents on ship. Timely elimination of host animals of hantavirus in port areas is necessary to prevent an outbreak of HVs disease.

Epidemiological study on the incidence of haemorrhagic fever with renal syndrome in five Western Balkan countries for a 10-year period: 2006-2015

BACKGROUND

Large-scale epidemics of haemorrhagic fever with renal syndrome (HFRS) have been reported mostly in Asia and Europe, with around 100,000 people affected each year. In the Southeast Europe, Balkan region, HFRS is endemic disease with approximately 100 cases per year. Our aim was to describe epidemiological characteristics of HFRS in five Western Balkan (WB) countries and to describe correlation between HFRS incidence and major meteorological event that hit the area in May 2014.

METHODS

National surveillance data of HFRS from Bosnia and Herzegovina, Croatia, Montenegro, North Macedonia and Serbia obtained from 1 January 2006 to 31 December 2015 were collected and analysed.

RESULTS

In a 10-year period, a total of 1,065 HFRS patients were reported in five WB countries. Cumulative incidence rate ranged from 0.05 to 15.80 per 100.000 inhabitants (in North Macedonia and Montenegro respectively). Increasing number of HFRS cases was reported with a peak incidence in three specific years (2008, 2012, and 2014). Average incidence for the entire area was higher in males than females (5.63 and 1.90 per 100.000 inhabitants respectively). Summer was the season with the highest number of cases and an average incidence rate of 1.74/100.000 inhabitants across 10-year period. Haemorrhagic fever with renal syndrome incidence was significantly increased (7.91/100.000 inhabitants) in 2014, when a few months earlier, severe floods affected several WB countries. A strong significant negative correlation (r = -.84, p < .01) between the monthly incidence of HFRS and the number of months after May's floods was demonstrated for the total area of WB.

CONCLUSION

Our findings demonstrate that the HFRS incidence had similar distribution (general, age, sex and seasonality) across majority of the included countries. Summer was the season with the highest recorded incidence. Common epidemic years were detected in all observed countries as well as a negative correlation between the monthly incidence of HFRS and the number of months after May's cyclone.

OUP accepted manuscript

Hantavirus-induced diseases are emerging zoonoses with endemic appearances and frequent outbreaks in different parts of the world. In humans, hantaviral pathology is characterized by the disruption of the endothelial cell barrier followed by increased capillary permeability, thrombocytopenia due to platelet activation/depletion and an overactive immune response. Genetic vulnerability due to certain human leukocyte antigen haplotypes is associated with disease severity. Typically, two different hantavirus-caused clinical syndromes have been reported: hemorrhagic fever with renal syndrome (HFRS) and hantavirus cardiopulmonary syndrome (HCPS). The primarily affected vascular beds differ in these two entities: renal medullary capillaries in HFRS caused by Old World hantaviruses and pulmonary capillaries in HCPS caused by New World hantaviruses. Disease severity in HFRS ranges from mild, e.g. Puumala virus-associated nephropathia epidemica, to moderate, e.g. Hantaan or Dobrava virus infections. HCPS leads to a severe acute respiratory distress syndrome with high mortality rates. Due to novel insights into organ tropism, hantavirus-associated pathophysiology and overlapping clinical features, HFRS and HCPS are believed to be interconnected syndromes frequently involving the kidneys. As there are no specific antiviral treatments or vaccines approved in Europe or the USA, only preventive measures and public awareness may minimize the risk of hantavirus infection. Treatment remains primarily supportive and, depending on disease severity, more invasive measures (e.g., renal replacement therapy, mechanical ventilation and extracorporeal membrane oxygenation) are needed.

Development and design of the Hantavirus registry - HantaReg - for epidemiological studies, outbreaks and clinical studies on hantavirus disease

Background

Frequent outbreaks around the globe and endemic appearance in different parts of the world emphasize the substantial risk of hantavirus diseases. Increasing incidence rates, trends of changing distribution of hantavirus species and new insights into clinical courses of hantavirus diseases call for multinational surveillance. Furthermore, evidence-based guidelines for the management of hantavirus diseases and scoring systems, which allow stratification of patients into risk categories, are lacking.

Methods

Hantavirus registry (HantaReg) is a novel registry platform facilitating multinational research of hantavirus-caused diseases, such as haemorrhagic fever with renal syndrome (HFRS) and hantavirus cardiopulmonary syndrome (HCPS). HantaReg provides an electronic case report form and uses the General Data Protection Regulation compliant platform clinicalsurveys.net, which can be accessed from any internet browser in the world. Having a modular structure, the registry platform is designed to display or hide questions and items according to the documented case (e.g. patient with HFRS versus HCPS) to facilitate fast, but standardized, data entry. Information categories documented in HantaReg are demographics, pre-existing diseases, clinical presentation, diagnostic and therapeutic approaches, as well as outcome.

Conclusions

HantaReg is a novel, ready-to-use platform for clinical and epidemiological studies on hantavirus diseases and facilitates the documentation of the disease course associated with hantavirus infections. HantaReg is expected to promote international collaboration and contributes to improving patient care through the analysis of diagnostic and treatment pathways for hantavirus diseases, providing evidence for robust treatment recommendations. Moreover, HantaReg enables the development of prognosis-indicating scoring systems for patients with hantavirus disease.

Impact of Landscape on Host-Parasite Genetic Diversity and Distribution Using the Puumala orthohantavirus-Bank Vole System

In nature, host specificity has a strong impact on the parasite's distribution, prevalence, and genetic diversity. The host's population dynamics is expected to shape the distribution of host-specific parasites. In turn, the parasite's genetic structure is predicted to mirror that of the host. Here, we study the tandem Puumala orthohantavirus (PUUV)-bank vole system. The genetic diversity of 310 bank voles and 33 PUUV isolates from 10 characterized localities of Northeast France was assessed. Our findings show that the genetic diversity of both PUUV and voles, was positively correlated with forest coverage and contiguity of habitats. While the genetic diversity of voles was weakly structured in space, that of PUUV was found to be strongly structured, suggesting that the dispersion of voles was not sufficient to ensure a broad PUUV dissemination. Genetic diversity of PUUV was mainly shaped by purifying selection. Genetic drift and extinction events were better reflected than local adaptation of PUUV. These contrasting patterns of microevolution have important consequences for the understanding of PUUV distribution and epidemiology.

Hantavirus infections in humans in Poland-current state of knowledge and perspectives for research

BACKGROUND

In Europe, hantaviruses cause serious human disease, hemorrhagic fever with renal syndrome (HFRS). The geographic distribution of human cases of HFRS is a consequence of distribution of reservoir host species. Epidemiology of HFRS is well-studied in Western Europe, while data from Central and Eastern Europe are poor or unavailable.

METHODS

The data on hantavirus infections in humans during 2007-2017 were gathered to distinguish pattern of HFRS occurrence and characterize potential factors shaping HFRS epidemiology in Poland.

RESULTS

The south-eastern part of Poland (Podkarpackie voivodeship) was recognized as endemic area of hantavirus prevalence. Incidence rate of HFRS in Poland was positively correlated with mast years and higher abundance of rodents, urbanization index, and forest cover, while the climatic factors (average temperatures in January and July and average annual precipitation) have had no significant impact.

CONCLUSIONS

In Poland, HFRS is still not recognized entity. Further studies on hantavirus infection rate in reservoir host species (rodents, shrews, and bats) and virus transmission to humans are needed to prevent outbreaks of HFRS in the future.

How Bank Vole-PUUV Interactions Influence the Eco-Evolutionary Processes Driving Nephropathia Epidemica Epidemiology-An Experimental and Genomic Approach

In Europe, Puumala virus (PUUV) is responsible for nephropathia epidemica (NE), a mild form of hemorrhagic fever with renal syndrome (HFRS). Despite the presence of its reservoir, the bank vole, on most of French territory, the geographic distribution of NE cases is heterogeneous and NE endemic and non-endemic areas have been reported. In this study we analyzed whether bank vole-PUUV interactions could partly shape these epidemiological differences. We performed crossed-experimental infections using wild bank voles from French endemic (Ardennes) and non-endemic (Loiret) areas and two French PUUV strains isolated from these areas. The serological response and dynamics of PUUV infection were compared between the four cross-infection combinations. Due to logistical constraints, this study was based on a small number of animals. Based on this experimental design, we saw a stronger serological response and presence of PUUV in excretory organs (bladder) in bank voles infected with the PUUV endemic strain. Moreover, the within-host viral diversity in excretory organs seemed to be higher than in other non-excretory organs for the NE endemic cross-infection but not for the NE non-endemic cross-infection. Despite the small number of rodents included, our results showed that genetically different PUUV strains and in a lesser extent their interaction with sympatric bank voles, could affect virus replication and diversity. This could impact PUUV excretion/transmission between rodents and to humans and in turn at least partly shape NE epidemiology in France.

Detection and Genetic Characterization of Puumala Orthohantavirus S-Segment in Areas of France Non-Endemic for Nephropathia Epidemica

Puumala virus (PUUV) in Europe causes nephropathia epidemica (NE), a mild form of hemorrhagic fever with renal syndrome (HFRS). The incidence of NE is highly heterogeneous spatially, whereas the geographic distribution of the wild reservoir of PUUV, the bank vole, is essentially homogeneous. Our understanding of the processes driving this heterogeneity remains incomplete due to gaps in knowledge. Little is known about the current distribution and genetic variation of PUUV in the areas outside the well-identified zones of NE endemicity. We trapped bank voles in four forests in French regions in which NE is considered non-endemic, but sporadic NE cases have been reported recently. We tested bank voles for anti-PUUV IgG and characterized the S segment sequences of PUUV from seropositive animals. Phylogenetic analyses revealed specific amino-acid signatures and genetic differences between PUUV circulating in non-endemic and nearby NE-endemic areas. We also showed, in temporal surveys, that the amino-acid sequences of PUUV had undergone fewer recent changes in areas non-endemic for NE than in endemic areas. The evolutionary history of the current French PUUV clusters was investigated by phylogeographic approaches, and the results were considered in the context of the history of French forests. Our findings highlight the need to monitor the circulation and genetics of PUUV in a larger array of bank vole populations, to improve our understanding of the risk of NE.

Temporal Dynamics of Two Pathogenic Hantaviruses Among Rodents in Hungary

Hantaviruses are worldwide pathogens, which often cause serious or even fatal diseases in humans. Hosts are predominantly in the form of rodents and soricomorphs; however, bats are also described as an important reservoir. In Hungary, representatives of two human pathogenic species of the genus Orthohantavirus are present: the Dobrava-Belgrade orthohantavirus and Puumala orthohantavirus. In Hungarian forests, the dominant rodent species are Apodemus flavicollis, Apodemus agrarius, Apodemus sylvaticus, and Myodes glareolus, all of which are natural reservoirs comprising different hantaviruses. The aim of the study was to survey the prevalence of hantaviruses among rodent populations and examine the potential relationship regarding population densities, years, sex, and seroprevalence. Rodents were trapped at 13 sampling plots in a forest reserve located in the Mecsek Mountain range, Hungary, from March to October between 2011 and 2014. Rodent serum samples were tested for IgG antibodies against Dobrava-Belgrade virus and Puumala virus by enzyme-linked immunosorbent assay (ELISA) using a recombinant nucleocapsid protein. During the 4-year sampling period, 2491 specimens were tested and 254 (10.2%) proved seropositive for orthohantaviruses. In 2011, the seroprevalence among Apodemus spp. and M. glareolus was 17.2% (114/661) and 3.9% (3/77), respectively, although this rate had reversed itself in 2014. Seropositivity was substantiated in 18.4% (12/65) of Myodes voles, while only 3.6% (13/359) of the tested Apodemus rodents were found to be IgG positive. Seroconversion was observed in 58 cases, while seroreversion was only detected in 3 individual cases. A significant difference among the number of infected males and females was identified in the first 2 years of our study. Winter survival with respect to rodents was not negatively affected due to the hantavirus infection. Hantavirus seroprevalence was not directly influenced by host abundance. Consequently, we assume that high rodent density alone does not lead to an increased risk of hantavirus infection among the rodent host population.

Dynamics of Puumala hantavirus outbreak in Black Sea Region, Turkey

BACKGROUND

Some of the hantavirus species in Euro-Asia cause haemorrhagic fever with renal syndrome (HFRS) in humans. The first documented human hantavirus infection in Turkey was diagnosed in 2009. This report describes the dynamics of the first hantavirus outbreak that emerged in humans in the Western Black Sea Region of Turkey.

METHODS

All the suspected cases of hantavirus infection were admitted to the Infectious Diseases and Clinical Microbiology Department at the Zonguldak Bülent Ecevit University Hospital in Zonguldak, Turkey. The patients were carefully interviewed, examined and evaluated using routine laboratory tests and hantavirus diagnostic tools. Hantavirus-reactive antibodies (IgM and IgG) in serum samples were detected via enzyme immune assay (EIA) and immunofluorescence assay (IFA) in the acute and convalescence stages of the disease. The presence of hantavirus ribonucleic acid (RNA) was analysed via reverse transcription polymerase chain reaction (RT-PCR) in serum and urine samples. A focus reduction neutralization test (FRNT) was performed to confirm specific hantavirus serotypes. In addition, a case-control study was conducted to identify possible risk factors for hantavirus transmission in the outbreak area. A control group was composed of asymptomatic individuals who were seronegative for hantavirus IgM and IgG and living in the outbreak area.

RESULTS

A total of 55 suspected cases of hantavirus infection were admitted to the inpatient clinic between February and June of 2009. Twenty-four patients were diagnosed with acute HFRS via EIA or IFA. In 22 of the 24 infected patients, Puumala virus (PUUV) was identified as the causative hantavirus type by detecting IgM in the acute stage and an increase in the IgG level in follow-up serum samples. PUUV was also verified as the infecting agent by FRNT in two of the 24 cases. Among the 24 laboratory-confirmed HFRS cases, 21 (87.5%) were males and 3 (12.5%) were females, and the mean age was 45.92 years (standard deviation ± 16.90 years). Almost all these individuals were living in villages or rural areas. The 24 HFRS cases were matched with 26 healthy controls for statistical analyses and according to binary logistic regression analysis, and dealing with rodent control activities in gardens or in annexes of their homes (p = 0.021 and Odds ratio [OR] = 17.11) and being male (p = 0.019 and OR = 22.37) were detected as statistically significant risk factors for hantavirus infection. The most commonly observed clinical complaints were fatigue (95.8%), shivering (91.7%), fever (87.1%), headache (70.8%) and nausea (70.8%). Haemodialysis was required for four patients (16.7%). Except for the first case diagnosed with acute hantavirus infection, no patient died. The mean delay time to hospital admission from initiation of symptoms was 5.3 days, the mean duration of febrile days was 2.6 days, and the mean duration of hospital stay was 8.5 days.

CONCLUSION

Hantaviruses are circulating in Turkey and causing sporadic or epidemic infection in humans. Additional investigations are needed to better understand the dynamics of hantaviruses in this country.

Molecular investigation of vector-borne parasites in wild micromammals, Barcelona (Spain)

Information about the role of micromammals in the epidemiology of Leishmania infantum and Babesia sp. in southern Europe is scarce. Wild micromammals were captured in natural areas in the Barcelona province (NE Spain) in 2011 and analysed by real-time PCR for the presence of DNA of Piroplasmida (n = 253) and Leishmania infantum (n = 166). The wood mouse (Apodemus sylvaticus) was the most abundant species, but all specimens tested negative for L. infantum, for which two out of 15 (13.3%) white-toothed shrews (Crocidura russula) and one out of 23 (4.3%) Algerian mice (Mus spretus) resulted positive. No individual was positive for Piroplasmida DNA. The role of wild micromammals in the epidemiology of these parasites in the study area seems negligible.

First insights into Puumala orthohantavirus circulation in a rodent population in Alsace, France

In-depth knowledge on the mechanisms that maintain infection by a zoonotic pathogen in an animal reservoir is the key to predicting and preventing transmission to humans. The Puumala orthohantavirus (PUUV), the most prevalent orthohantavirus in Western Europe, causes a mild form of haemorrhagic fever with renal syndrome (HFRS) in humans. In France, this endemic illness affects the north-eastern part of the country. We conducted a 4-year capture-mark-recapture study in a bank vole population, combined with molecular analyses, to explore the epidemiological situation of PUUV in Alsace, a French region where human cases have occurred, but for which no studies have been conducted on this reservoir host. PUUV-infected bank voles were detected in the 2 years that showed high bank vole density with a prevalence of 4%. The individual PUUV sequences identified in this study were similar from year to year and similar to other French sequences. On a very small spatial scale, the distribution of seropositive bank voles was very heterogeneous in time and space. The short distances travelled on average by bank voles resulted in spatial clusters of seropositive rodents, which spread only very gradually throughout the year.

Hantaviruses and a neglected environmental determinant

Most human pathogenic hantaviruses cause severe hemorrhagic fevers with a high rate of fatalities, such as occurs due to the genotypes causing hantavirus cardiopulmonary syndrome carried by the New World Sigmodontinae and Neotominae rodents. An increasing number of outbreaks and the possibility of cases spreading over international borders have led to greater interest in these viruses and the environmental determinants that facilitate their transmission. Rodents, shrews, moles and bats act as reservoir hosts of hantaviruses, and within the hantavirus transmission flow, the prevalence and distribution of infection in reservoir hosts is influenced by a range of factors. Climate change and landscape alteration affect hantavirus transmission, but the outcomes can differ among different hantaviruses and for the same virus in differentbiomes. However, it is evident that the underlying mechanisms that mediate hantavirus transmission are largely unknown, so that much work remains to be done regarding the transmission dynamics of hantaviruses. Overall, our review highlights the importance of examining interactions over several trophic levels and the underlying mechanisms (density and trait-mediated indirect effects) linking predation risk and hantavirus transmission, to develop an ecological framework to understand disease in natural, preserved and degraded systems.