Epidemic characteristics of hemorrhagic fever with renal syndrome in China, 2006-2012

Clinical Characteristics and a Novel Prediction Nomogram (EASTAR) for Patients with Hemorrhagic Fever with Renal Syndrome: A Multicenter Retrospective Study

BACKGROUND

The fatality rate of hemorrhagic fever with renal syndrome (HFRS), due to hantavirus transmitted by rodents, ranges from 1% to 12%. This study aims to delineate the clinical and laboratory characteristics of HFRS, identify factors associated with disease severity, and construct and validate a nomogram for prognosis prediction of HFRS in the central part of China.

METHODS

Out of 598 HFRS patients diagnosed via serology tests from four hospitals in Hubei Province, 551 were included. Clinical data were gathered and analyzed, followed by logistic univariate and multivariate analyses to identify independent prognostic factors. A nomogram was developed and validated to forecast the patient's prognosis.

RESULTS

Vaccination led to a notable drop in HFRS incidence from 2018 to 2019, and seasonal trends exhibited bimodal changes with peaks from May to July and November to January. The 30-day mortality rate was 4.17% (23/551). Red blood cell count (RBC), age, two-stage overlap, qSOFA ≥ 2, aspartate aminotransferase (AST), and three-stage overlap were identified as independent prognostic factors. A predictive risk classification system using a nomogram chart was developed, and Kaplan-Meier curves indicated that the new system accurately distinguished 30-day mortality among the three risk groups.

CONCLUSIONS

The risk score (EASTAR) system demonstrated good predictive performance for prognostic prediction, and it can be applied to quickly screen patients who require ICU admission.

Risk of hemorrhagic fever with renal syndrome associated with meteorological factors in diverse epidemic regions: a nationwide longitudinal study in China

BACKGROUND

Hemorrhagic fever with renal syndrome (HFRS) is a climate-sensitive zoonotic disease that poses a significant public health burden worldwide. While previous studies have established associations between meteorological factors and HFRS incidence, there remains a critical knowledge gap regarding the heterogeneity of these effects across diverse epidemic regions. Addressing this gap is essential for developing region-specific prevention and control strategies. This study conducted a national investigation to examine the associations between meteorological factors and HFRS in three distinct epidemic regions.

METHODS

We collected daily meteorological data (temperature and relative humidity) and HFRS incidence cases of 285 cities in China from the Resource and Environment Science and Data Center and the Chinese National Notifiable Infectious Disease Reporting Information System from 2005-2022. Study locations were stratified into three distinct epidemic categories (Rattus-dominant, Apodemus-dominant, and mixed) based on the seasonality of peak incidence. The associations between meteorological variables and HFRS incidence were investigated using a time-stratified case-crossover design combined with distributed lag nonlinear modeling for each epidemic category.

RESULTS

The exposure-response relationships between meteorological factors and HFRS incidence revealed significant heterogeneity across epidemic regions, as evidenced by Cochran's Q test for temperature (Q = 324.40, P < 0.01) and relative humidity (Q = 30.57, P < 0.01). The optimal daily average temperature for HFRS transmission in Rattus-dominant epidemic regions (- 6.6 °C), characterized by spring epidemics, was lower than that observed in Apodemus-dominant epidemic regions (13.7 °C), where primary cases occurred during autumn and winter months. Furthermore, the association between relative humidity and HFRS incidence exhibited as a monotonic negative correlation in Rattus-dominant regions, while Apodemus-dominant regions showed a nonlinear, inverted U-shaped association.

CONCLUSIONS

This study highlights the heterogeneous effects of meteorological factors on HFRS incidence across different epidemic regions. Targeted preventive measures should be taken during cold and dry spring days in Rattus-dominant regions, and during warm and moderately humid winter days in Apodemus-dominant regions. In mixed epidemic regions, both scenarios require attention. These findings provide novel scientific evidence for the formulation and implementation of region-specific HFRS prevention policies.

Investigation on the Epidemic Situation of Epidemic Hemorrhagic Fever in an Island Industrial Park in Zhoushan, China

Objective: To investigate the epidemic factors of hemorrhagic fever with renal syndrome (HFRS) and compare the S and M gene sequences of hantavirus (HV) between rodents and the infected cases. Methods: Detailed epidemiological investigations were conducted on the cases' working and living areas. Captured rodents were classified by night trapping method, and their lungs and blood were collected for virus carriage detection after aseptic dissection. Viral S and M fragments of HV RNA were amplified and sequenced from positive samples of cases and mice, and their homology was analyzed. Results: After reconstruction, the geographic and living environment changed significantly, altering rodent behaviors. The industrial park, characterized by high population density, poor living conditions, and frequent contact of rodent (feces) and humans, had a high rodent density and HV virus infection ratio. Four workers infected with HV were positive for anti-HV immunoglobulin G (IgG) and IgM. Among the positive samples, HV RNA was detected in all two cases, and four Rattus norvegicus specimens were Seoul type HV S3 subtype. The virus had the closest relationship with Rod/2012/QHD/4/Gc (Hebei, China) and RuianRn180 (Zhejiang, China), with the 100% homology of M gene segment. The homology of viral S gene segment exhibited the closest relationship with the Jiangxi isolated JiangxiXinjianRn-09-2011, ranging from 99.6% to 99.8%. Conclusion: The HV sequencing showed a strong epidemiological relationship between the cases and host rodents. Improving living environmental health conditions, administering HFRS vaccine, and reducing rodent density and human-rodent contact can mitigate the risk of HFRS.

Development of an all-in-one real-time PCR assay for simultaneous detection of spotted fever group rickettsiae, severe fever with thrombocytopenia syndrome virus and hantaan virus prevalent in central China

Central China has been reported to be one of the most important endemic areas of zoonotic infection by spotted fever group rickettsiae (SFGR), severe fever with thrombocytopenia syndrome virus (SFTSV) and hantaan virus (HTNV). Due to similar clinical symptoms, it is challenging to make a definite diagnosis rapidly and accurately in the absence of microbiological tests. In the present study, an all-in-one real-time PCR assay was developed for the simultaneous detection of nucleic acids from SFGR, SFTSV and HTNV. Three linear standard curves for determining SFGR-ompA, SFTSV-L and HTNV-L were obtained within the range of 101-106 copies/μL, with the PCR amplification efficiencies ranging from 93.46% to 96.88% and the regression coefficients R2 of >0.99. The detection limit was 1.108 copies/μL for SFGR-ompA, 1.075 copies/μL for SFTSV-L and 1.006 copies/μL for HTNV-L, respectively. Both the within-run and within-laboratory coefficients of variation on the cycle threshold (Ct) values were within the range of 0.53%-2.15%. It was also found there was no statistical difference in the Ct values between single template and multiple templates (PSFGR-ompA = 0.186, PSFTSV-L = 0.612, PHTNV-L = 0.298). The sensitivity, specificity, positive and negative predictive value were all 100% for determining SFGR-ompA and SFTSV-L, 97%, 100%, 100% and 99.6% for HTNV-L, respectively. Therefore, the all-in-one real-time PCR assay appears to be a reliable, sensitive, rapid, high-throughput and low cost-effective method to diagnose the zoonotic infection by SFGR, SFTSV and HTNV.

Spatial-temporal patterns and influencing factors for hemorrhagic fever with renal syndrome: A 16-year national surveillance analysis in China

Background

China is confronted with the significant menace posed by hemorrhagic fever with renal syndrome (HFRS). Nevertheless, the long-term spatial-temporal variations, regional prevalence patterns, and fundamental determinants' mechanisms for HFRS remain inadequately elucidated.

Methods

Newly diagnosed cases of HFRS from January 2004 to December 2019 were acquired from the China Public Health Science Data repository. We used Age-period-cohort and Bayesian Spacetime Hierarchy models to identify high-risk populations and regions in mainland China. Additionally, the Geographical Detector model was employed to quantify the determinant powers of significant driver factors to the disease.

Results

A total of 199,799 cases of HFRS were reported in mainland China during 2004-2019. The incidence of HFRS declined from 1.93 per 100,000 in 2004 to 0.69 per 100,000 in 2019. The incidence demonstrated an inverted U-shaped trend with advancing age, peaking in the 50-54 age group, with higher incidences observed among individuals aged 20-74 years. Hyperendemic areas were mainly concentrated in the northeastern regions of China, while some western provinces exhibited a potential upward trend. Geographical detector model identified that the spatial variations of HFRS were significantly associated with the relative humidity (Q = 0.36), forest cover (Q = 0.26), rainfall (Q = 0.18), temperature (Q = 0.16), and the surface water resources (Q = 0.14).

Conclusions

This study offered comprehensive examinations of epidemic patterns, identified high-risk areas quantitatively, and analyzed factors influencing HFRS transmission in China. The findings may contribute to the necessary implementations for the effective prevention and control of HFRS.

Epidemiology of Hemorrhagic Fever with Renal Syndrome and Host Surveillance in Zhejiang Province, China, 1990-2021

Hemorrhagic fever with renal syndrome (HFRS) is caused by hantaviruses (HVs) and is endemic in Zhejiang Province, China. In this study, we aimed to explore the changing epidemiology of HFRS cases and the dynamics of hantavirus hosts in Zhejiang Province. Joinpoint regression was used to analyze long-term trends in the incidence of HFRS. The comparison of animal density at different stages was conducted using the Mann-Whitney Test. A comparison of HV carriage rates between stages and species was performed using the chi-square test. The incidence of HFRS shows a continuous downward trend. Cases are widely distributed in all counties of Zhejiang Province except Shengsi County. There was a high incidence belt from west to east, with low incidence in the south and north. The HFRS epidemic showed two seasonal peaks in Zhejiang Province, which were winter and summer. It showed a marked increase in the age of the incidence population. A total of 23,073 minibeasts from 21 species were captured. Positive results were detected in the lung tissues of 14 rodent species and 1 shrew species. A total of 80% of the positive results were from striped field mice and brown rats. No difference in HV carriage rates between striped field mice and brown rats was observed (χ2 = 0.258, p = 0.611).

Epidemiological characteristics and prediction model construction of hemorrhagic fever with renal syndrome in Quzhou City, China, 2005-2022

Background

Hemorrhagic fever with renal syndrome (HFRS) is one of the 10 major infectious diseases that jeopardize human health and is distributed in more than 30 countries around the world. China is the country with the highest number of reported HFRS cases worldwide, accounting for 90% of global cases. The incidence level of HFRS in Quzhou is at the forefront of Zhejiang Province, and there is no specific treatment for it yet. Therefore, it is crucial to grasp the epidemiological characteristics of HFRS in Quzhou and establish a prediction model for HFRS to lay the foundation for early warning of HFRS.

Methods

Descriptive epidemiological methods were used to analyze the epidemic characteristics of HFRS, the incidence map was drawn by ArcGIS software, the Seasonal AutoRegressive Integrated Moving Average (SARIMA) and Prophet model were established by R software. Then, root mean square error (RMSE) and mean absolute error (MAE) were used to evaluate the fitting and prediction performances of the model.

Results

A total of 843 HFRS cases were reported in Quzhou City from 2005 to 2022, with the highest annual incidence rate in 2007 (3.93/100,000) and the lowest in 2022 (1.05/100,000) (P trend<0.001). The incidence is distributed in a seasonal double-peak distribution, with the first peak from October to January and the second peak from May to July. The incidence rate in males (2.87/100,000) was significantly higher than in females (1.32/100,000). Farmers had the highest number of cases, accounting for 79.95% of the total number of cases. The incidence is high in the northwest of Quzhou City, with cases concentrated on cultivated land and artificial land. The RMSE and MAE values of the Prophet model are smaller than those of the SARIMA (1,0,1) (2,1,0)12 model.

Conclusion

From 2005 to 2022, the incidence of HFRS in Quzhou City showed an overall downward trend, but the epidemic in high-incidence areas was still serious. In the future, the dynamics of HFRS outbreaks and host animal surveillance should be continuously strengthened in combination with the Prophet model. During the peak season, HFRS vaccination and health education are promoted with farmers as the key groups.

Pathogenicity of novel hantavirus isolate and antigenicity and immunogenicity of novel strain-based inactivated vaccine

BACKGROUND

Hantaan virus (HTNV, Orthohantavirus hantanensae species, Hantaviridae family) is the main etiological agent responsible for hemorrhagic fever with renal syndrome (HFRS). The novel HTNV may pose a potential danger to the control and prevention of HFRS in China, which highlights the importance of vaccine development in public health management. In previous studies, our laboratory discovered and successfully isolated a new HTNV strain, HV004 strain, from Apodemus agrarius captured in an epidemic area in Hubei, China.

METHODS

An initial biological and pathogenicity characterization of HTNV 76-118 (standard train), HV114 strain (a clinical isolate from Hubei province in 1986), and the novel isolate HV004 strain from the epidemic areas of Hubei province were performed in susceptible cells and in vivo. An experimental HV004 strain inactivated vaccine was prepared, and its corresponding immunogenicity was analyzed in BALB/c mice.

RESULTS

HV004 strain had a similar but higher pathogenicity than HTNV 76-118 and HV114 in suckling mice. A subcutaneous vaccination (s.c.) with the inactivated HTNV vaccine adjuvanted with aluminum, followed by a challenge intraperitoneally with 106 FFU/ml HTNV, afforded full protection against an HTNV challenge. All immunized mice in every group elicited serum neutralizing antibodies with increasing dosages, which may protect mice from HTNV infection. A dose-dependent stimulation index of splenocytes was also observed in immunized mice. The percentage of IFN-γ-producing CD3+CD8+ T cells was significantly higher in the spleens of immunized mice than in those of control mice.

CONCLUSIONS

These findings suggest that the inactivated HTNV vaccine may stimulate mice to produce high levels of antibodies with neutralization activity and elicit specific anti-HTNV humoral and cellular immune responses in BALB/c mice against the prevalent strain of HTNV in south central China.

The ecological and etiological investigation of ticks and rodents in China: results from an ongoing surveillance study in Zhejiang Province

OBJECTIVES

This study aimed to analyze the population density of vector ticks and reservoir hosts rodents, and to investigate the relevant pathogen infection in Zhejiang Province, China.

METHODS

In this surveillance study, the data of ticks density were collected with the tick picking method on animal body surface and the drag-flag method, while the rodent density with the night trapping method. The samples of ticks were examined for the severe fever with thrombocytopenia syndrome virus (SFTSV), and blood serum and organs from rodents were subjected for SFTSV, hantavirus, Leptospira, Orientia tsutsugamushi (O. tsutsugamushi) and Yersinia pestis (Y. pestis) screening in the laboratory.

RESULTS

From 2017 to 2022 in Zhejiang Province, 16,230 parasitic ticks were found in 1848 positive animals, with the density of parasitic ticks of 1.29 ticks per host animal, and a total of 5,201 questing ticks were captured from 1,140,910 meters of vegetation distance with the questing tick density of 0.46 ticks/flag·100 m. Haemaphysalis longicornis (H. longicornis) was the major species. A total of 2,187,739 mousetraps were distributed and 12,705 rodents were trapped, with the density of 0.58 per 100 trap-nights. Rattus norvegicus was the major species. For SFTSV screening, two groups nymphal ticks of H. longicornis were tested to be positive. For the rodents samples, the Leptospira had a positive rate of 12.28% (197/1604), the hantavirus was 1.00% (16/1604), and the O. tsutsugamushi was 0.15% (2/1332). No positive results were found with SFTSV and Y. pestis in the rodents samples.

CONCLUSION

Findings from this study indicated that the ticks and rodents were widely distributed in Zhejiang Province. Particularly, the positive detection of SFTSV, Leptospira, hantavirus and O. tsutsugamushi in ticks or rodents from this area suggested that more attention should be paid to the possibilities of relevant vector-borne diseases occurrence.

Hantavirus: an overview and advancements in therapeutic approaches for infection

Hantaviruses are a significant and emerging global public health threat, impacting more than 200,000 individuals worldwide each year. The single-stranded RNA viruses belong to the Hantaviridae family and are responsible for causing two acute febrile diseases in humans: Hantavirus pulmonary syndrome (HPS) and hemorrhagic fever with renal syndrome (HFRS). Currently, there are no licensed treatments or vaccines available globally for HTNV infection. Various candidate drugs have shown efficacy in increasing survival rates during the early stages of HTNV infection. Some of these drugs include lactoferrin, ribavirin, ETAR, favipiravir and vandetanib. Immunotherapy utilizing neutralizing antibodies (NAbs) generated from Hantavirus convalescent patients show efficacy against HTNV. Monoclonal antibodies such as MIB22 and JL16 have demonstrated effectiveness in protecting against HTNV infection. The development of vaccines and antivirals, used independently and/or in combination, is critical for elucidating hantaviral infections and the impact on public health. RNA interference (RNAi) arised as an emerging antiviral therapy, is a highly specific degrades RNA, with post-transcriptional mechanism using eukaryotic cells platform. That has demonstrated efficacy against a wide range of viruses, both in vitro and in vivo. Recent antiviral methods involve using small interfering RNA (siRNA) and other, immune-based therapies to target specific gene segments (S, M, or L) of the Hantavirus. This therapeutic approach enhances viral RNA clearance through the RNA interference process in Vero E6 cells or human lung microvascular endothelial cells. However, the use of siRNAs faces challenges due to their low biological stability and limited in vivo targeting ability. Despite their successful inhibition of Hantavirus replication in host cells, their antiviral efficacy may be hindered. In the current review, we focus on advances in therapeutic strategies, as antiviral medications, immune-based therapies and vaccine candidates aimed at enhancing the body's ability to control the progression of Hantavirus infections, with the potential to reduce the risk of severe disease.

Clinical and Molecular Epidemiology of Hemorrhagic Fever with Renal Syndrome Caused by Orthohantaviruses in Xiangyun County, Dali Prefecture, Yunnan Province, China

Hemorrhagic fever with renal syndrome (HFRS) is a zoonotic disease transmitted by several rodent species. We obtained clinical data of HFRS patients from the medical records of the People's Hospital of Xiangyun County in Dali Prefecture from July 2019 to August 2021. We collected epidemiological data of HFRS patients through interviews and investigated host animals using the night clip or night cage method. We systematically performed epidemiological analyses of patients and host animals. The differences in the presence of rodent activity at home (χ2 = 8.75, p = 0.031 < 0.05), of rodent-proof equipment in the food (χ2 = 9.19, p = 0.025 < 0.05), and of rodents or rodent excrement in the workplace (χ2 = 10.35, p = 0.014 < 0.05) were statistically different in the four clinical types, including mild, medium, severe, and critical HFRS-associated diseases. Furthermore, we conducted molecular detection of orthohantavirus in host animals. The total orthohantavirus infection rate of rodents was 2.72% (9/331); the specific infection rate of specific animal species was 6.10% (5/82) for the Apodemus chevrieri, 100% (1/1) for the Rattus nitidus, 3.77% (2/53) for the Rattus norvegicus, and 12.50% (1/8) for the Crocidura dracula. In this study, a total of 21 strains of orthohantavirus were detected in patients and rodents. The 12 orthohantavirus strains from patients showed a closer relationship with Seoul orthohantavirus (SEOOV) L0199, DLR2, and GZRn60 strains; the six orthohantavirus strains from Rattus norvegicus and Apodemus chevrieri were closely related to SEOOV GZRn60 strain. One strain (XYRn163) from Rattus norvegicus and one strain (XYR.nitidus97) from Rattus nitidus were closely related to SEOOV DLR2 strain; the orthohantavirus strain from Crocidura dracula was closely related to the Luxi orthohantavirus (LUXV) LX309 strain. In conclusion, patients with HFRS in Xuangyun County of Dali Prefecture are predominantly affected by SEOOV, with multiple genotypes of orthohantavirus in host animals, and, most importantly, these orthohantavirus strains constantly demonstrated zoonotic risk in humans.

Orthohantavirus infections in humans and rodents in the Yichun region, China, from 2016 to 2021

BACKGROUND

Rodents are the predominant natural hosts of orthohantavirus and the source of human infection, hemorrhagic fever with renal syndrome (HFRS) caused by orthohantavirus is a severe public health problem in the Yichun region, Jiangxi Province, China. However, little information is known about the infection of orthohantavirus in humans and rodents, and the genetic characteristics of the epidemic orthohantavirus in the region.

METHODS

The clinical data of HFRS cases in 2016-2021 was analyzed. Virus infection in rodents was analyzed by orthohantavirus antigen detection using immunofluorescent assay, and the species of orthohantaviruses in rodents and patients were identified by real-time RT-PCR and gene sequencing. The S and M segments of orthohantaviruses from rodents and patients were recovered and analyzed.

RESULTS

A total of 1,573 HFRS cases were reported in the Yichun region from 2016 to 2021, including 11 death cases. HFRS cases peaked twice each year: in winter from November to January and early summer from May to June. Farmers constituted the predominant population suffering from HFRS. The orthohantavirus antigen was identified in five species of rodents: Apodemus agrarius (A. agrarius), Rattus norvegicus (R. norvegicus), Sorex araneus, Rattus losea (R. losea), and Niviventer confucianus (N. confucianus). The real-time RT-PCR test and genetic analysis results showed that Hantaan orthohantavirus (HTNV), Seoul orthohantavirus (SEOV), and Dabieshan orthohantavirus (DBSV) were circulated in the rodents. HTNV, SEOV, and DBSV from the rodents were distantly related to other known orthohantaviruses and belonged to novel genetic lineages. SEOV and HTNV were found in HFRS patients, but 97.8% (90/92) of the infections were caused by HTNV. Winter and early summer peaks were both caused by HTNV. The HTNV sequences recovered from HFRS cases were closely related to those from A. agrarius.

CONCLUSIONS

In the Yichun region, the orthohantaviruses transmitted in rodents include HTNV, SEOV, and DBSV, which have obvious genetic characteristics and high genetic diversity. At the same time, this region is an HFRS mixed epidemic area dominated by HTNV, with two peaks every year, which deserves our high attention.

The Spatiotemporal Pattern and Its Determinants of Hemorrhagic Fever With Renal Syndrome in Northeastern China: Spatiotemporal Analysis

BACKGROUND

Hemorrhagic fever with renal syndrome (HFRS) is a significant zoonotic disease mainly transmitted by rodents. However, the determinants of its spatiotemporal patterns in Northeast China remain unclear.

OBJECTIVE

This study aimed to investigate the spatiotemporal dynamics and epidemiological characteristics of HFRS and detect the meteorological effect of the HFRS epidemic in Northeastern China.

METHODS

The HFRS cases of Northeastern China were collected from the Chinese Center for Disease Control and Prevention, and meteorological data were collected from the National Basic Geographic Information Center. Times series analyses, wavelet analysis, Geodetector model, and SARIMA model were performed to identify the epidemiological characteristics, periodical fluctuation, and meteorological effect of HFRS in Northeastern China.

RESULTS

A total of 52,655 HFRS cases were reported in Northeastern China from 2006 to 2020, and most patients with HFRS (n=36,558, 69.43%) were aged between 30-59 years. HFRS occurred most frequently in June and November and had a significant 4- to 6-month periodicity. The explanatory power of the meteorological factors to HFRS varies from 0.15 ≤ q ≤ 0.01. In Heilongjiang province, mean temperature with a 4-month lag, mean ground temperature with a 4-month lag, and mean pressure with a 5-month lag had the most explanatory power on HFRS. In Liaoning province, mean temperature with a 1-month lag, mean ground temperature with a 1-month lag, and mean wind speed with a 4-month lag were found to have an effect on HFRS, but in Jilin province, the most important meteorological factors for HFRS were precipitation with a 6-month lag and maximum evaporation with a 5-month lag. The interaction analysis of meteorological factors mostly showed nonlinear enhancement. The SARIMA model predicted that 8,343 cases of HFRS are expected to occur in Northeastern China.

CONCLUSIONS

HFRS showed significant inequality in epidemic and meteorological effects in Northeastern China, and eastern prefecture-level cities presented a high risk of epidemic. This study quantifies the hysteresis effects of different meteorological factors and prompts us to focus on the influence of ground temperature and precipitation on HFRS transmission in future studies, which could assist local health authorities in developing HFRS-climate surveillance, prevention, and control strategies targeting high-risk populations in China.

Correlation analysis of CD8+ cell overexpression and prognosis of hemorrhagic fever with renal syndrome-a case-control study

Background

Hemorrhagic fever with Renal Syndrome (HFRS) is an infectious disease caused by Hantavirus with fever, hemorrhage and acute kidney injury (AKI) as clinical characteristics. The research on the etiology and pathogenesis of diseases has become a focus of attention. However, there are few related medical studies in children with HFRS. The prognosis of the children with HFRS remains to be explored.

Objectives

We explored risk factors in children with HFRS and summarize sensitive indicators that are conducive to the prognosis of the disease.

Methods

We designed a case-control study and recruited 182 HFRS pediatric patients (2014.01-2022.08). They were divided into two groups according to the severity of disease, including the control group(158 cases with mild and moderate subgroup)and the observation group (24 cases with severe and critical subgroup). Risk factors influencing prognosis were analyzed by binary logistic regression. The cutoff value, sensitivity and specificity of the risk factors prediction were calculated by receiver operating characteristic (ROC) and Yoden index.

Results

Lymphocyte subsets characteristics analysis showed that in observation group the indexes were decreased in lymphocyte, T lymphocytes (CD3)⁺, helper/inducible T lymphocytes (CD4⁺)/inhibition/cytotoxic T cells (CD8⁺), B lymphocytes (CD19⁺); and the elevated index was CD8⁺, the difference were all significant between two groups. (P < 0.05). With death as the primary outcome, it was found that the serum CD8⁺ (odds ratio [OR] 2.91, 95% confidence interval [CI] 1.65, 4.00; P < 0.01) was risk factor and significantly associated with mortality. The cutoff value of the serum CD8⁺ was 845 × 10⁶/L, the sensitivity and specificity were 78.5%, 85.4%. With complications as the secondary outcomes, the serum CD8⁺ (OR 2.69, 95% CI 1.15, 4.88; P < 0.01) was found to be risk factors. The cutoff of the serum CD8⁺ was 690 × 10⁶/L, the sensitivity and specificity were 69.3%, 75.1% respectively.

Conclusion

CD8⁺ may be significantly correlated with the severity and prognosis of HFRS in children.

Clinical and laboratory features and factors predicting disease severity in pediatric patients with hemorrhagic fever with renal syndrome caused by Hantaan virus

The clinical features and factors associated with disease severity in children with hemorrhagic fever with renal syndrome (HFRS) have not been well characterized. This study analyzed the clinical and laboratory factors associated with disease severity in children with HFRS caused by Hantaan virus. Data in pediatric patients with HFRS were retrospectively collected from Xi'an Children's Hospital over a 9-year period. Independent factors associated with disease severity were identified. Nomogram predicting disease severity was constructed based on variables filtered by feature selection. In total, 206 children with HFRS were studied. Fever, digestive tract symptoms, headache, backache, bleeding, and renal injury signs were the common symptoms. Elevated white blood cell, reduced platelet, hematuria, proteinuria, coagulation abnormalities, increased blood urea nitrogen (BUN) and procalcitonin (PCT), decreased estimated glomerular filtration rate and low serum Na⁺ , Cl^- , and Ca²⁺ were the common laboratory findings. In the 206 patients, 21 patients had critical type disease and 4 patients (1.9%) died. Hydrothorax, hypotension and cerebral edema/cerebral herniation at hospital admission were independent clinical characteristics, and neutrophil %, prothrombin activity, PCT, BUN, and Ca²⁺ at hospital admission were independent laboratory factors associated with critical disease. Feature selection identified BUN, PCT and prothrombin time as independent factors related to critical disease. A nomogram integrating BUN and PCT at admission was constructed and calibration showed high accuracy for the probability prediction of critical disease. In conclusion, this study characterized the clinical and laboratory features and constructed a nomogram predicting disease severity in pediatric HFRS, providing references for disease severity evaluation in managing children HFRS.

Factors associated with hemorrhagic fever with renal syndrome based maximum entropy model in Zhejiang Province, China

Background

Hemorrhagic fever with renal syndrome (HFRS) is a serious public health problem in China. The geographic distribution has went throughout China, among which Zhejiang Province is an important epidemic area. Since 1963, more than 110,000 cases have been reported.

Methods

We collected the meteorological factors and socioeconomic indicators of Zhejiang Province, and constructed the HFRS ecological niche model of Zhejiang Province based on the algorithm of maximum entropy.

Results

Model AUC from 2009 to 2018, is 0.806–0.901. The high incidence of epidemics in Zhejiang Province is mainly concentrated in the eastern, western and central regions of Zhejiang Province. The contribution of digital elevation model ranged from 2009 to 2018 from 4.22 to 26.0%. The contribution of average temperature ranges from 6.26 to 19.65%, Gross Domestic Product contribution from 7.53 to 21.25%, and average land surface temperature contribution with the highest being 16.73% in 2011. In addition, the average contribution of DMSP/OLS, 20-8 precipitation and 8-20 precipitation were all in the range of 9%. All-day precipitation increases with the increase of rainfall, and the effect curve peaks at 1,250 mm, then decreases rapidly, and a small peak appears again at 1,500 mm. Average temperature response curve shows an inverted v-shape, where the incidence peaks at 17.8^°C. The response curve of HFRS for GDP and DMSP/OLS shows a positive correlation.

Conclusion

The incidence of HFRS in Zhejiang Province peaked in areas where the average temperature was 17.8^°C, which reminds that in the areas where temperature is suitable, personal protection should be taken when going out as to avoid contact with rodents. The impact of GDP and DMSP/OLS on HFRS is positively correlated. Most cities have good medical conditions, but we should consider whether there are under-diagnosed cases in economically underdeveloped areas.

Expert Consensus on the Prevention and Treatment of Hemorrhagic Fever with Renal Syndrome

Abstract

Hemorrhagic fever with renal syndrome (HFRS) is an acute zoonosis with a global distribution. China is one of the countries with a high incidence of HFRS, which has long endangered the lives and health of the Chinese people. The Infectious Disease Branch of the Chinese Preventive Medicine Association and the Infectious Diseases Branch of the Chinese Medical Association organized national multidisciplinary experts, based on domestic and international research results combined with experts’ practical experiences, to reach this consensus after thorough discussion. This consensus contains 17 recommendations aimed at prevention and identification of important clinical issues to further standardize the prevention, diagnosis, and treatment of HFRS.

Hemorrhagic fever with renal syndrome caused by destruction of residential area of rodent in a construction site: epidemiological investigation

BACKGROUND

An outbreak of hemorrhagic fever with renal syndrome (HFRS), caused by a Hantavirus, affected nine adult males in the southwest area of Xi'an in November 2020 was analyzed in this study.

METHODS

Clinical and epidemiological data of HFRS patients in this outbreak were retrospectively analyzed. The whole genome of a hantavirus named 201120HV03xa (hv03xa for short) isolated from Apodemus agrarius captured in the construction site was sequenced and analyzed. In addition, nine HFRS patients were monitored for the IgG antibody against the HV N protein at 6 and 12 months, respectively.

RESULTS

In this study, inhalation of aerosolized excreta and contaminated food may be the main source of infection. Genome analysis and phylogenetic analysis showed that hv03xa is a reassortment strain of HTNV, having an S segment related to A16 of HTN 4, an M segment related to Q37 and Q10 of HTN 4, and an L segment related to prototype strain 76-118 of HTN 7. Potential recombination was detected in the S segment of hv03xa strain. The anti-HV-IgG level of all the patients persist for at least one year after infection.

CONCLUSIONS

This report documented an HFRS outbreak in Xi'an, China, which provided the basic data for epidemiological surveillance of endemic HTNV infection and facilitated to predict disease risk and implement prevention measures.

Spatiotemporal and Seasonal Trends of Class A and B Notifiable Infectious Diseases in China: A Retrospective Analysis (Preprint)

BACKGROUND

China is the most populous country globally and has made significant achievements in the control of infectious diseases over the last decades. The 2003 SARS epidemic triggered the initiation of the China Information System for Disease Control and Prevention (CISDCP). Since then, numerous studies have investigated the epidemiological features and trends of individual infectious diseases in China; however, few considered the changing spatiotemporal trends and seasonality of these infectious diseases over time.

OBJECTIVE

This study aims to systematically review the spatiotemporal trends and seasonal characteristics of class A and class B notifiable infectious diseases in China during 2005-2020.

METHODS

We extracted the incidence and mortality data of 8 types (27 diseases) of notifiable infectious diseases from the CISDCP. We used the Mann-Kendall and Sen's methods to investigate the diseases' temporal trends, Moran I statistic for their geographical distribution, and circular distribution analysis for their seasonality.

RESULTS

Between January 2005 and December 2020, 51,028,733 incident cases and 261,851 attributable deaths were recorded. Pertussis (P=.03), dengue fever (P=.01), brucellosis (P=.001), scarlet fever (P=.02), AIDS (P<.001), syphilis (P<.001), hepatitis C (P<.001) and hepatitis E (P=.04) exhibited significant upward trends. Furthermore, measles (P<.001), bacillary and amebic dysentery (P<.001), malaria (P=.04), dengue fever (P=.006), brucellosis (P=.03), and tuberculosis (P=.003) exhibited significant seasonal patterns. We observed marked disease burden-related geographic disparities and heterogeneities. Notably, high-risk areas for various infectious diseases have remained relatively unchanged since 2005. In particular, hemorrhagic fever and brucellosis were largely concentrated in Northeast China; neonatal tetanus, typhoid and paratyphoid, Japanese encephalitis, leptospirosis, and AIDS in Southwest China; BAD in North China; schistosomiasis in Central China; anthrax, tuberculosis, and hepatitis A in Northwest China; rabies in South China; and gonorrhea in East China. However, the geographical distribution of syphilis, scarlet fever, and hepatitis E drifted from coastal to inland provinces during 2005-2020.

CONCLUSIONS

The overall infectious disease burden in China is declining; however, hepatitis C and E, bacterial infections, and sexually transmitted infections continue to multiply, many of which have spread from coastal to inland provinces.

Adenosine Deaminase is a Potential Molecular Marker for Diagnosis and Prognosis of Haemorrhagic Fever with Renal Syndrome

Objective

Haemorrhagic fever with renal syndrome (HFRS) is a serious zoonotic disease which seriously endangers physical health and mainly occurs in China. To date, there is still a lack of early and novel biomarkers to detect the severity of disease and prognosis of HFRS. This study was aimed to examine the value of the serum Adenosine deaminase (ADA) concentrations in the patients with HFRS.

Methods

The clinical and laboratory data of 124 adult patients with HFRS and 131 patients with similar clinical symptoms to HFRS were analyzed. A receiver operating characteristic (ROC) curve was used to analyze the diagnostic value of ADA in HFRS.

Results

The ADA levels in the serum of HFRS patients were significantly higher than those in control patients (P < 0.001), and ADA has a strong positive correlation with HFRS (r = 0.785, P < 0.001). The optimal cut-off value of ADA for diagnosis of HFRS was 18 U/L and the area under the curve (AUC) was 0.953 (95% CI: 0.925, 0.981). The sensitivity was 84.8%, the specificity was 93.1%, the positive predictive value was 92.2%, the negative predictive value was 86.5% and the Youden index was 77.9%. Serum ADA levels in patients with HFRS tended to decrease at discharge compared with those at admission.

Conclusion

ADA could be a potential molecular marker for diagnosis and prognosis of HFRS patients.

Central nervous system infection with Seoul Orthohantavirus in a child after hematopoietic stem cell transplantation: a case report

Background

Patients with allogeneic hematopoietic stem cell transplantation (allo-HSCT) are prone to complicate viral infection. Central nervous system (CNS) involvement caused by the viruses is rare but with poor prognosis. Hantavirus, which usually cause hemorrhagic fever with renal syndrome (HFRS), and none case has been reported about these infection in allo-HSCT patients.

Case presentation

In August 2021, a 13-year-old male child developed intermittent fever and refractory hypotension after allo-HSCT. Magnetic resonance imaging of the head revealed abnormal signal foci in the left midbrain cerebral peduncle and bilateral thalamus. His family reported traces of mouse activity in the patient’s home kitchen. HFRS was suspected, but with no significant kidney damage. The specific immunoglobulin (Ig) G and M of hantavirus were negative. The metagenomic next-generation sequencing (mNGS) detected Seoul Orthohantavirus (SEOV) sequences directly in cerebrospinal fluid and blood.

Conclusions

Allo-HSCT patients are a high-risk group for infection. Usually the causative agent of infection is difficult to determine, and sometimes the site of infection is concealed. This report highlights the importance of suspecting hantavirus infection in allo-HSCT patients with CNS symptoms despite the absence of renal syndromes. The mNGS is a powerful tool for detecting pathogens. CNS infection with Seoul orthohantavirus in transplant patients is rare but possible as demonstrated in this case. To the best of our knowledge, this is the first reported case employing mNGS to diagnose SEOV caused CNS infection in an allo-HSCT patient.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12985-022-01766-6.

The Clinical Characteristics and Outcomes of Hemorrhagic Fever With Renal Syndrome in Pregnancy

Pregnant women with hemorrhagic fever with renal syndrome (HFRS) are a significant challenge for clinicians. The clinical characteristics of HFRS in pregnant women and its influence on both the pregnant women and fetus have yet to be clarified clearly. To highlight the specific clinical features of HFRS in pregnant women and the outcomes of pregnant women with HFRS and their fetuses, we screened pregnant women with HFRS from inception to May 1^st 2021. We also conducted a comparison with non-pregnant women complicated with HFRS. Twenty-seven pregnant women and 87 non-pregnant women with complete electronic medical records were enrolled for final analyses; 55.6% (15/27) and 21.8% (19/87) were diagnosed as critical type in pregnant women and non-pregnant women, respectively. Compared with non-pregnant patients, there was a significantly higher likelihood of critical status in pregnant patients; the risk was significantly higher in late trimester (p <0.001). In addition, hypoalbuminemia and anemia were also evident in pregnant patients (p = 0.04, p <0.001, respectively). Leukocyte count, especially when higher than 15 × 10⁹/L, was significantly correlated with disease severity (p = 0.009). After comprehensive therapy, 26 pregnant patients recovered without sequelae. Five fetal adverse events were reported during hospitalization. All adverse events were observed in mothers with critical types (p = 0.047, X₂ = 4.909) and occurred in the later trimester. Collectively, our data show that pregnant woman with HFRS during the third trimester presents a more severe condition, especially those with leukocytosis. However, the majority of those pregnant patients could recover with comprehensive treatment and undergo normal labor.

Hemorrhagic Fever with Renal Syndrome: Literature Review, Epidemiology, Clinical Picture and Pathogenesis

Hantaviruses can cause two types of infections in humans: hemorrhagic fever with renal syndrome (HFRS) and hantavirus pulmonary syndrome. The old world hantaviruses, primarily Hantaan virus (HTNV), responsible for causing HFRS occurs endemically in Asia and Europe. Apodernus agraricus, a striped field mouse, is being considered as main host reservoir for HTNV. Infection in humans is typically accidental and occurs when virus-containing rodent excretions such as urine, feces, or saliva are aerosolized. The major clinical manifestations includes increased vascular permeability causing vascular leakage, acute kidney injury and coagulation abnormalities. The case fatality rate of HFRS varies around 5.0 - 10.0% depending on the causative viral agent. The direct effects of viral infection on endothelial cells, as well as the immunological response to the viral infection, have been suggested to play a key role in the pathogenesis of HFRS. This article summarizes the current knowledge of HFRS epidemiology in Korea and around the globe, etiology, host transmission, clinical presentation, pathogenesis, diagnostic techniques, treatment, and prevention.

Survey of rodent-borne pathogens in Singapore reveals the circulation of Leptospira spp., Seoul hantavirus, and Rickettsia typhi

Rodents living alongside humans increases the probability of encounter and also the transmission of rodent-borne diseases. Singapore’s cosmopolitan urban landscape provides a perfect setting to study the prevalence of four rodent-borne pathogens: Seoul hantavirus (SEOV), Leptospira species, Rickettsia typhi and Yersinia pestis, and identify the potential risk factors which may influence rodent density and transmission of rodent-borne diseases. A total of 1143 rodents were trapped from 10 unique landscape structures throughout Singapore. Real-time quantitative Polymerase Chain Reactions were used to detect pathogenic and intermediate Leptospira spp. and Yersinia pestis, whereas the seroprevalence of SEOV and R. typhi were analysed by Enzyme-Linked Immunosorbent Assay and Immunofluorescence Assay respectively. Multivariable logistic regression analysis was used to evaluate the association between prevalence of infection in rodent reservoirs and risk factors. Most of the rodents were caught in public residential developments (62.2%). Among the tested rodents, 42.4% were infected with Leptospira spp., while 35.5% and 32.2% were seropositive for SEOV and R. typhi respectively, whereas Yersinia pestis was not detected. Furthermore, risk factors including habitat, species, gender, and weight of rodents, influenced prevalence of infection to a varying extent. This study highlights the presence of Leptospira spp., SEOV and R. typhi in Singapore’s rodent population, suggesting the need for effective rodent management and sanitation strategies to prevent further circulation and transmission to humans.

Spatiotemporal association of rapid urbanization and water-body distribution on hemorrhagic fever with renal syndrome: A case study in the city of Xi'an, China

Hemorrhagic fever with renal syndrome (HFRS) is a zoonosis characterized by clinical features of high fever, hemorrhage, and renal damage. China has the largest number of HFRS cases worldwide, accounting for over 90% of the total reported cases. In this paper, we used surveyed HFRS data and satellite imagery to conduct geostatistical analysis for investigating the associations of rapid urbanization, water bodies, and other factors on the spatiotemporal dynamics of HFRS from year 2005 to 2018 in Xi'an City, Northwest China. The results revealed an evident epidemic aggregation in the incidence of HFRS within Xi'an City with a phenomenal fluctuation in periodic time series. Rapid urbanization was found to greatly affect the HFRS incidence in two different time phases. HFRS caused by urbanization influences farmers to a lesser extent than it does to non-farmers. The association of water bodies with the HFRS incidence rate was found to be higher within the radii of 696.15 m and 1575.39 m, which represented significant thresholds. The results also showed that geomatics approaches can be used for spatiotemporally investigating the HFRS dynamic characteristics and supporting effective allocations of resources to formulate strategies for preventing epidemics.

Detection and Genetic Characterization of Seoul Virus in Liver Tissue Samples From Rattus norvegicus and Rattus tanezumi in Urban Areas of Southern China

Rodents are important hosts of hantaviruses, and lungs and kidneys are known to be the preferred organs of these viruses. Recently, hantaviruses were detected in liver samples from wild rodents in Hungary and the United States, and feeder rats in the Netherlands. However, few studies have detected hantaviruses in the liver of rats from China. In this study, hantaviruses were investigated in liver samples from R. norvegicus and R. tanezumi trapped in urban areas of southern China. A total of 461 R. norvegicus and 64 R. tanezumi were trapped. Using a pan-hantavirus PCR method, hantaviruses were detected in liver, lung, and serum samples from these animals. About 7.43% of liver samples were positive for Seoul virus (SEOV). The detection rate of SEOV in liver samples from R. norvegicus (8.24%) was higher than that from R. tanezumi (1.56%), suggesting the predominant role of R. norvegicus in the transmission of SEOV in urban areas of China. Three R. norvegicus had SEOV RNA in their liver samples but not in their lung samples, suggesting that the liver might be one of the targeted organs of SEOV. The first full SEOV protein-coding sequences (CDS) of the S and M segments, and partial CDS of the L segment from R. tanezumi were amplified. Several full and partial CDS of the S, M, and L segments from R. norvegicus were also obtained. The SEOV sequences obtained from different animals were highly similar, suggesting the cross-species transmission potential of SEOV between R. norvegicus and R. tanezumi.

The association of ABO blood types with host susceptibility to hemorrhagic fever with renal syndrome

Since the discovery of ABO blood types, there has been mounting evidence of the association between blood types and infectious diseases. However, so far, there is rarely available research about the potential role of ABO blood types in haemorrhagic fever with renal syndrome (HFRS) infection. Our aim was to investigate the relationship between ABO blood types and the development of HFRS infection in Qingdao, China. We carried out a retrospective study enrolling 116 HFRS patients as the case group and 373 healthy subjects as the control group. ABO blood type distribution was analysed using the Chi-square test and logistic regression analysis. Results showed that the distribution of ABO blood types between the two groups was significantly different (X2 = 18.151, P < 0.05). Blood type B was less frequently observed [odds ratio (OR), 0.404; confidence interval (CI), 0.238–0.684; P < 0.01], while blood type AB was more frequently observed in the case group (OR, 2.548; CI, 1.427–4.549; P < 0.01). Since significantly more males were affected than females, we further analysed the data by gender as well as blood types and obtained consistent results for males. Our findings indicated that populations with blood type AB might be more prone to HFRS infection, whereas those with blood type B might be less susceptible to HFRS infection, which will help to make risk stratification in infection control.

Epidemiological Characteristics and Regional Risk Prediction of Hemorrhagic Fever with Renal Syndrome in Shandong Province, China

BACKGROUND

Hemorrhagic fever with renal syndrome (HFRS), a rodent-borne disease caused by different species of hantaviruses, is widely endemic in China. Shandong Province is one of the most affected areas. This study aims to analyze the epidemiological characteristics of HFRS, and to predict the regional risk in Shandong Province.

METHODS

Descriptive statistics were used to elucidate the epidemiological characteristics of HFRS cases in Shandong Province from 2010 to 2018. Based on environmental and socioeconomic data, the boosted regression tree (BRT) model was applied to identify important influencing factors, as well as predict the infection risk zones of HFRS.

RESULTS

A total of 11,432 HFRS cases were reported from 2010 to 2018 in Shandong, with groups aged 31-70 years (81.04%), and farmers (84.44%) being the majority. Most cases were from central and southeast Shandong. There were two incidence peak periods in April to June and October to December, respectively. According to the BRT model, we found that population density (a relative contribution of 15.90%), elevation (12.02%), grassland (11.06%), cultivated land (9.98%), rural settlement (9.25%), woodland (8.71%), and water body (8.63%) were relatively important influencing factors for HFRS epidemics, and the predicted high infection risk areas were concentrated in central and eastern areas of Shandong Province. The BRT model provided an overall prediction accuracy, with an area under the receiver operating characteristic curve of 0.91 (range: 0.83-0.95).

CONCLUSIONS

HFRS in Shandong Province has shown seasonal and spatial clustering characteristics. Middle-aged and elderly farmers are a high-risk population. The BRT model has satisfactory predictive capability in stratifying the regional risk of HFRS at a county level in Shandong Province, which could serve as an important tool for risk assessment of HFRS to deploy prevention and control measures.

Development and validation of a nomogram for predicting severity in patients with hemorrhagic fever with renal syndrome: A retrospective study

Background

Hemorrhagic fever with renal syndrome (HFRS) is a zoonotic disease caused by hantavirus infection. Patients with severe HFRS may develop multiple organ failure or even death, which makes HFRS a serious public health problem.

Methods

In this retrospective study, we included a total of 155 consecutive patients who were diagnosed with HFRS, of whom 109 patients served as a training cohort and 46 patients as an independent verification cohort. In the training set, the least absolute shrinkage and selection operator (LASSO) regression was used to screen the characteristic variables of the risk model. Multivariate logistic regression analysis was used to construct a nomogram containing the characteristic variables selected in the LASSO regression model.

Results

The area under the receiver operating characteristic curve (AUC) of the nomogram indicated that the model had good discrimination. The calibration curve exhibited that the nomogram was in good agreement between the prediction and the actual observation. Decision curve analysis and clinical impact curve suggested that the predictive nomogram had clinical utility.

Conclusion

In this study, we established a simple and feasible model to predict severity in patients with HFRS, with which HFRS would be better identified and patients can be treated early.

Epidemic Trend and Molecular Evolution of HV Family in the Main Hantavirus Epidemic Areas From 2004 to 2016, in P.R. China

Hemorrhagic fever with renal syndrome (HFRS) is caused by hantavirus (HV) infection, and is prevalent across Europe and Asia (mainly China). The genetic variation and wide host range of the HV family may lead to vaccine failure. In this study, we analyzed the gene sequences of HV isolated from different regions of China in order to trace the molecular evolution of HV and the epidemiological trends of HFRS. A total of 16,6975 HFRS cases and 1,689 HFRS-related deaths were reported from 2004 to 2016, with the average annual incidence rate of 0.9674 per 100,000, 0.0098 per 100,000 mortality rate, and case fatality rate 0.99%. The highest number of cases were detected in 2004 (25,041), and after decreasing to the lowest numbers (8,745) in 2009, showed an incline from 2010. The incidence of HFRS is the highest in spring and winter, and three times as many men are affected as women. In addition, farmers account for the largest proportion of all cases. The main hosts of HV are Rattus norvegicus and Apodemus agrarius, and the SEOV strain is mainly found in R. norvegicus and Niviventer confucianus. Phylogenetic analysis showed that at least 10 HTNV subtypes and 6 SEOV subtypes are endemic to China. We found that the clustering pattern of M genome segments was different from that of the S segments, indicating the possibility of gene recombination across HV strains. The recent increase in the incidence of HFRS may be related to climatic factors, such as temperature, relative humidity and hours of sunshine, as well as biological factors like rodent density, virus load in rodents and genetic variation. The scope of vaccine application should be continuously expanded, and surveillance measures and prevention and control strategies should be improved to reduce HFRS infection in China.

Epidemic Trend and Molecular Evolution of HV Family in the Main Hantavirus Epidemic Areas From 2004 to 2016, in P.R. China

Hemorrhagic fever with renal syndrome (HFRS) is caused by hantavirus (HV) infection, and is prevalent across Europe and Asia (mainly China). The genetic variation and wide host range of the HV family may lead to vaccine failure. In this study, we analyzed the gene sequences of HV isolated from different regions of China in order to trace the molecular evolution of HV and the epidemiological trends of HFRS. A total of 16,6975 HFRS cases and 1,689 HFRS-related deaths were reported from 2004 to 2016, with the average annual incidence rate of 0.9674 per 100,000, 0.0098 per 100,000 mortality rate, and case fatality rate 0.99%. The highest number of cases were detected in 2004 (25,041), and after decreasing to the lowest numbers (8,745) in 2009, showed an incline from 2010. The incidence of HFRS is the highest in spring and winter, and three times as many men are affected as women. In addition, farmers account for the largest proportion of all cases. The main hosts of HV are Rattus norvegicus and Apodemus agrarius, and the SEOV strain is mainly found in R. norvegicus and Niviventer confucianus. Phylogenetic analysis showed that at least 10 HTNV subtypes and 6 SEOV subtypes are endemic to China. We found that the clustering pattern of M genome segments was different from that of the S segments, indicating the possibility of gene recombination across HV strains. The recent increase in the incidence of HFRS may be related to climatic factors, such as temperature, relative humidity and hours of sunshine, as well as biological factors like rodent density, virus load in rodents and genetic variation. The scope of vaccine application should be continuously expanded, and surveillance measures and prevention and control strategies should be improved to reduce HFRS infection in China.

Decoding the RNA viromes in rodent lungs provides new insight into the origin and evolutionary patterns of rodent-borne pathogens in Mainland Southeast Asia

BACKGROUND

As the largest group of mammalian species, which are also widely distributed all over the world, rodents are the natural reservoirs for many diverse zoonotic viruses. A comprehensive understanding of the core virome of diverse rodents should therefore assist in efforts to reduce the risk of future emergence or re-emergence of rodent-borne zoonotic pathogens.

RESULTS

This study aimed to describe the viral range that could be detected in the lungs of rodents from Mainland Southeast Asia. Lung samples were collected from 3284 rodents and insectivores of the orders Rodentia, Scandentia, and Eulipotyphla in eighteen provinces of Thailand, Lao PDR, and Cambodia throughout 2006-2018. Meta-transcriptomic analysis was used to outline the unique spectral characteristics of the mammalian viruses within these lungs and the ecological and genetic imprints of the novel viruses. Many mammalian- or arthropod-related viruses from distinct evolutionary lineages were reported for the first time in these species, and viruses related to known pathogens were characterized for their genomic and evolutionary characteristics, host species, and locations.

CONCLUSIONS

These results expand our understanding of the core viromes of rodents and insectivores from Mainland Southeast Asia and suggest that a high diversity of viruses remains to be found in rodent species of this area. These findings, combined with our previous virome data from China, increase our knowledge of the viral community in wildlife and arthropod vectors in emerging disease hotspots of East and Southeast Asia. Video abstract.

A comprehensive screening of the whole proteome of hantavirus and designing a multi-epitope subunit vaccine for cross-protection against hantavirus: Structural vaccinology and immunoinformatics study

Hantaviruses are an emerging zoonotic group of rodent-borne viruses that are having serious implications on global public health due to the increase in outbreaks. Since there is no permanent cure, there is increasing interest in developing a vaccine against the hantavirus. This research aimed to design a robust cross-protective subunit vaccine using a novel immunoinformatics approach. After careful evaluation, the best predicted cytotoxic & helper T-cell and B-cell epitopes from nucleocapsid proteins, glycoproteins, RdRp proteins, and non-structural proteins were considered as potential vaccine candidates. Among the four generated vaccine models with different adjuvant, the model with toll-like receptor-4 (TLR-4) agonist adjuvant was selected because of its high antigenicity, non-allergenicity, and structural quality. The selected model was 654 amino acids long and had a molecular weight of 70.5 kDa, which characterizes the construct as a good antigenic vaccine candidate. The prediction of the conformational B-lymphocyte (CBL) epitope secured its ability to induce the humoral response. Thereafter, disulfide engineering improved vaccine stability. Afterwards, the molecular docking confirmed a good binding affinity of -1292 kj/mol with considered immune receptor TLR-4 and the dynamics simulation showed high stability of the vaccine-receptor complex. Later, the in silico cloning confirmed the better expression of the constructed vaccine protein in E. coli K12. Finally, in in silico immune simulation, significantly high levels of immunoglobulin M (IgM), immunoglobulin G1 (IgG1), cytotoxic & helper T lymphocyte (CTL & HTL) populations, and numerous cytokines such as interferon-γ (IFN-γ), interleukin-2 (IL-2) etc. were found as coherence with actual immune response and also showed faster antigen clearance for repeated exposures. Nonetheless, experimental validation can demonstrate the safety and cross-protective ability of the proposed vaccine to fight against hantavirus infection.

Hemorrhagic fever with renal syndrome complicated with aortic dissection: A case report

BACKGROUND

Hemorrhagic fever with renal syndrome is caused by hantaviruses presenting with high fever, hemorrhage, and acute kidney injury. Microvascular injury and hemorrhage in mucus were often observed in patients with hantavirus infection. Infection with bacterial and virus related aortic aneurysm or dissection occurs sporadically. Here, we report a previously unreported case of hemorrhagic fever with concurrent aortic dissection.

CASE SUMMARY

A 56-year-old man complained of high fever and generalized body ache, with decreased platelet counts of 10 × 10⁹/L and acute kidney injury. The enzyme-linked immunosorbent assays test for immunoglobulin M and immunoglobulin G hantavirus-specific antibodies were both positive. During the convalescent period, he complained sudden onset acute chest pain radiating to the back, and the computed tomography angiography revealed an aortic dissection of the descending aorta extending to iliac artery. He was diagnosed with hemorrhagic fever with renal syndrome and Stanford B aortic dissection. The patient recovered completely after surgery with other support treatments.

CONCLUSION

Hemorrhagic fever with renal syndrome complicated with aortic dissection is rare and a difficult clinical condition. Hantavirus infection not only causes microvascular damage presenting with hemorrhage but may be risk factor for acute macrovascular detriment. A causal relationship has yet to be confirmed.

Rare case of intracranial hemorrhage associated with seoul virus infection diagnosed by metagenomic next-generation sequencing

BACKGROUND

Seoul virus (SEOV) is a Hantavirus and the causative pathogen of Hemorrhagic Fever with Renal Syndrome (HFRS). Diagnosing SEOV infection is difficult because the clinical presentations are often undistinguishable from other viral or bacterial infections. In addition, diagnostic tools including serological and molecular assays are not readily available in the clinical settings.

CASE REPORT

A 57-year-old male presented with fever and a sudden loss of consciousness in November 2019. Computed tomography (CT) scan showed subdural hematoma, subfalcine herniation, and brain infarction. He developed thrombocytopenia and elevated transaminases, but no rashes or obvious kidney damage. He reported having a rat bite. HFRS was suspected. The Hantavirus IgG was positive, and the metagenomic next-generation sequencing (mNGS) detected SEOV sequences directly in the blood.

CONCLUSION

This report highlights the importance of suspecting SEOV infection in febrile patients with thrombocytopenia and elevated liver enzymes despite the absence of hemorrhagic manifestations of skin and renal syndromes. Next-generation sequencing is a powerful tool for pathogen detection. Intracranial hemorrhage and brain infarction as extrarenal manifestations of HFRS are rare but possible as demonstrated in this case.

Exploring the Dynamics of Hemorrhagic Fever with Renal Syndrome Incidence in East China Through Seasonal Autoregressive Integrated Moving Average Models

Objective

The purpose of this study was to explore the dynamics of incidence of hemorrhagic fever with renal syndrome (HFRS) from 2000 to 2017 in Anqiu City, a city located in East China, and find the potential factors leading to the incidence of HFRS.

Methods

Monthly reported cases of HFRS and climatic data from 2000 to 2017 in the city were obtained. Seasonal autoregressive integrated moving average (SARIMA) models were used to fit the HFRS incidence and predict the epidemic trend in Anqiu City. Univariate and multivariate generalized additive models were fit to identify and characterize the association between the HFRS incidence and meteorological factors during the study period.

Results

Statistical analysis results indicate that the annualized average incidence at the town level ranged from 1.68 to 6.31 per 100,000 population among 14 towns in the city, and the western towns exhibit high endemic levels during the study periods. With high validity, the optimal SARIMA(0,1,1,)(0,1,1)₁₂ model may be used to predict the HFRS incidence. Multivariate generalized additive model (GAM) results show that the HFRS incidence increases as sunshine time and humidity increases and decreases as precipitation increases. In addition, the HFRS incidence is associated with temperature, precipitation, atmospheric pressure, and wind speed. Those are identified as the key climatic factors contributing to the transmission of HFRS.

Conclusion

This study provides evidence that the SARIMA models can be used to characterize the fluctuations in HFRS incidence. Our findings add to the knowledge of the role played by climate factors in HFRS transmission and can assist local health authorities in the development and refinement of a better strategy to prevent HFRS transmission.

Time series analysis of temporal trends in hemorrhagic fever with renal syndrome morbidity rate in China from 2005 to 2019

Hemorrhagic fever with renal syndrome (HFRS) is seriously endemic in China with 70%~90% of the notified cases worldwide and showing an epidemic tendency of upturn in recent years. Early detection for its future epidemic trends plays a pivotal role in combating this threat. In this scenario, our study investigates the suitability for application in analyzing and forecasting the epidemic tendencies based on the monthly HFRS morbidity data from 2005 through 2019 using the nonlinear model-based self-exciting threshold autoregressive (SETAR) and logistic smooth transition autoregressive (LSTAR) methods. The experimental results manifested that the SETAR and LSTAR approaches presented smaller values among the performance measures in both two forecasting subsamples, when compared with the most extensively used seasonal autoregressive integrated moving average (SARIMA) method, and the former slightly outperformed the latter. Descriptive statistics showed an epidemic tendency of downturn with average annual percent change (AAPC) of −5.640% in overall HFRS, however, an upward trend with an AAPC = 1.213% was observed since 2016 and according to the forecasts using the SETAR, it would seemingly experience an outbreak of HFRS in China in December 2019. Remarkably, there were dual-peak patterns in HFRS incidence with a strong one occurring in November until January of the following year, additionally, a weak one in May and June annually. Therefore, the SETAR and LSTAR approaches may be a potential useful tool in analyzing the temporal behaviors of HFRS in China.

Monitoring Neutralization Property Change of Evolving Hantaan and Seoul Viruses with a Novel Pseudovirus-Based Assay

The Hantaan virus (HTNV) and Seoul virus (SEOV) mutants have accumulated over time. It is important to determine whether their neutralizing epitopes have evolved, thereby making the current vaccine powerless. However, it is impossible to determine by using traditional plaque reduction neutralization test (PRNT), because it requires large numbers of live mutant strains. Pseudovirus-based neutralization assays (PBNA) were developed by employing vesicular stomatitis virus (VSV) backbone incorporated with HTNV or SEOV glycoproteins (VSVΔG^*-HTNVG or VSVΔG^*-SEOVG). 56 and 51 single amino acid substitutions of glycoprotein (GP) in HTNV and SEOV were selected and introduced into the reference plasmid. Then the mutant pseudoviruses were generated and tested by PBNA. The PBNA results were highly correlated with PRNT ones with R² being 0.91 for VSVΔG^*-HTNVG and 0.82 for VSVΔG^*-SEOVG. 53 HTNV mutant pseudoviruses and 46 SEOV mutants were successfully generated. Importantly, by using PBNA, we found that HTNV or SEOV immunized antisera could neutralize all the corresponding 53 HTNV mutants or the 46 SEOV mutants respectively. The novel PBNA enables us to closely monitor the effectiveness of vaccines against large numbers of evolving HTNV and SEOV. And the current vaccine remains to be effective for the naturally occurring mutants.

Hemorrhagic Fever with Renal Syndrome - Liaoning Province, China, 1999-2018

What is already known on this topic?

Hemorrhagic fever with renal syndrome (HFRS) is endemic in Liaoning Province. Both Seoul and Hantaan virus are circulating in rodents, and epidemic outbreaks and sporadic cases have been recorded every year since the disease was recognized.

What is added by this report?

The epidemic trend of HFRS over the past 20 years (1999-2018) in Liaoning was analyzed, which showed both regional complexity and consistence with the epidemic in China. Genetic and antigenic stability of the circulating hantavirus were demonstrated, which suggested the effectiveness of the approved inactivated vaccine currently used in China.

What are the implications for public health practice?

Precise risk-based strategic practices that are integrated and regional are required for further improvement of the prevention and control of HFRS.

Therapeutic effect of Xuebijing combined with thymosin on hemorrhagic fever with renal syndrome: A protocol of systematic review and meta-analysis

BACKGROUND

The goal of this study is to assess the therapeutic effect of Xuebijing combined with thymosin (XBJ-T) for the treatment of patients with hemorrhagic fever with renal syndrome (HFRS).

METHODS

We will search the electronic databases of Cochrane Library, PUBMED, EMBASE, PsycINFO, Scopus, Opengrey, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Google scholar, Allied and Complementary Medicine Database, and Chinese Biomedical Literature Database from inception to the present. No language and publication status will be employed in this study. Based on the predefined eligibility criteria, selection of study and data extraction will be performed by 2 researchers independently. Study quality will be assessed using Cochrane risk of bias tool. We will apply RevMan 5.3 software to pool and analyze the extracted data.

RESULTS

This study will assess the therapeutic effect of XBJ-T for the treatment of patients with HFRS.

CONCLUSION

The findings of this study may provide systematic evidence to judge whether XBJ-T is an effective and safety intervention for HFRS.

STUDY REGISTRATION NUMBER

INPLASY202040068.

The Differential Characteristics Between Severe Fever With Thrombocytopenia Syndrome and Hemorrhagic Fever With Renal Syndrome in the Endemic Regions

An effective differentiation between severe fever with thrombocytopenia syndrome and hemorrhagic fever with renal syndrome was attained by a model considering patients’ age, mouse/tick contact, presence of blush, low back pain, diarrhea, enlarged lymph nodes, and white blood cell count.

A case-control study on the risk factors for hemorrhagic fever with renal syndrome

BACKGROUND

Hemorrhagic fever with renal syndrome (HFRS) is an endemic communicable disease in China, accounting for 90% of total reported cases worldwide. In this study, the authors want to investigate the risk factors for HFRS in recent years to provide the prevention and control advices.

METHODS

A community-based, 1:2 matched case-control study was carried out to investigate the risk factors for HFRS. Cases were defined as laboratory-confirmed cases that tested positive for hantavirus-specific IgM antibodies. Two neighbourhood controls of each case were selected by sex, age and occupation. Standardized questionnaires were used to collect information and identify the risk factors for HFRS.

RESULTS

Eighty-six matched pairs were investigated in the study. The median age of the cases was 55.0 years, 72.09% were male, and 73.26% were farmers. In the multivariate logistic regression analysis, cleaning spare room at home (OR = 3.310, 95%CI 1.335-8.210) was found to be risk factor for infection; storing food and crops properly (OR = 0.279 95%CI 0.097-0.804) provided protection from infection.

CONCLUSION

Storing food and crops properly seemed to be protective factor, which was important for HFRS prevention and control. More attention should be paid to promote comprehensive health education and behaviour change among high-risk populations in the HFRS endemic area.

Vaccines and Therapeutics Against Hantaviruses

Hantaviruses (HVs) are rodent-transmitted viruses that can cause hantavirus cardiopulmonary syndrome (HCPS) in the Americas and hemorrhagic fever with renal syndrome (HFRS) in Eurasia. Together, these viruses have annually caused approximately 200,000 human infections worldwide in recent years, with a case fatality rate of 5–15% for HFRS and up to 40% for HCPS. There is currently no effective treatment available for either HFRS or HCPS. Only whole virus inactivated vaccines against HTNV or SEOV are licensed for use in the Republic of Korea and China, but the protective efficacies of these vaccines are uncertain. To a large extent, the immune correlates of protection against hantavirus are not known. In this review, we summarized the epidemiology, virology, and pathogenesis of four HFRS-causing viruses, HTNV, SEOV, PUUV, and DOBV, and two HCPS-causing viruses, ANDV and SNV, and then discussed the existing knowledge on vaccines and therapeutics against these diseases. We think that this information will shed light on the rational development of new vaccines and treatments.

Epidemiological and time series analysis of haemorrhagic fever with renal syndrome from 2004 to 2017 in Shandong Province, China

Shandong Province is an area of China with a high incidence of haemorrhagic fever with renal syndrome (HFRS); however, the general epidemic trend of HFRS in Shandong remains unclear. Therefore, we established a mathematical model to predict the incidence trend of HFRS and used Joinpoint regression analysis, a generalised additive model (GAM), and other methods to evaluate the data. Incidence data from the first half of 2018 were included in a range predicted by a modified sum autoregressive integrated moving average-support vector machine (ARIMA-SVM) combination model. The highest incidence of HFRS occurred in October and November, and the annual mortality rate decreased by 7.3% (p < 0.05) from 2004 to 2017. In cold months, the incidence of HFRS increased by 4%, −1%, and 0.8% for every unit increase in temperature, relative humidity, and rainfall, respectively; in warm months, this incidence changed by 2%, −3%, and 0% respectively. Overall, HFRS incidence and mortality in Shandong showed a downward trend over the past 10 years. In both cold and warm months, the effects of temperature, relative humidity, and rainfall on HFRS incidence varied. A modified ARIMA-SVM combination model could effectively predict the occurrence of HFRS.

Comparison of autoregressive integrated moving average model and generalised regression neural network model for prediction of haemorrhagic fever with renal syndrome in China: a time-series study

OBJECTIVES

Haemorrhagic fever with renal syndrome (HFRS) is a serious threat to public health in China, accounting for almost 90% cases reported globally. Infectious disease prediction may help in disease prevention despite some uncontrollable influence factors. This study conducted a comparison between a hybrid model and two single models in forecasting the monthly incidence of HFRS in China.

DESIGN

Time-series study.

SETTING

The People's Republic of China.

METHODS

Autoregressive integrated moving average (ARIMA) model, generalised regression neural network (GRNN) model and hybrid ARIMA-GRNN model were constructed by R V.3.4.3 software. The monthly reported incidence of HFRS from January 2011 to May 2018 were adopted to evaluate models' performance. Root mean square error (RMSE), mean absolute error (MAE) and mean absolute percentage error (MAPE) were adopted to evaluate these models' effectiveness. Spatial stratified heterogeneity of the time series was tested by month and another GRNN model was built with a new series.

RESULTS

The monthly incidence of HFRS in the past several years showed a slight downtrend and obvious seasonal variation. A total of four plausible ARIMA models were built and ARIMA(2,1,1) (2,1,1)12 model was selected as the optimal model in HFRS fitting. The smooth factors of the basic GRNN model and the hybrid model were 0.027 and 0.043, respectively. The single ARIMA model was the best in fitting part (MAPE=9.1154, MAE=89.0302, RMSE=138.8356) while the hybrid model was the best in prediction (MAPE=17.8335, MAE=152.3013, RMSE=196.4682). GRNN model was revised by building model with new series and the forecasting performance of revised model (MAPE=17.6095, MAE=163.8000, RMSE=169.4751) was better than original GRNN model (MAPE=19.2029, MAE=177.0356, RMSE=202.1684).

CONCLUSIONS

The hybrid ARIMA-GRNN model was better than single ARIMA and basic GRNN model in forecasting monthly incidence of HFRS in China. It could be considered as a decision-making tool in HFRS prevention and control.

The characteristics of current natural foci of hemorrhagic fever with renal syndrome in Shandong Province, China, 2012-2015

BACKGROUND

Hemorrhagic fever with renal syndrome (HFRS), an infectious disease caused by hantaviruses, is endemic in China and remains a serious public health problem. Historically, Shandong Province has had the largest HFRS burden in China. However, we do not have a comprehensive and clear understanding of the current epidemic foci of HFRS in Shandong Province.

METHODOLOGY/PRINCIPAL FINDINGS

The incidence and mortality rates were calculated, and a phylogenetic analysis was performed after laboratory testing of the virus in rodents. Spatial epidemiology analysis was applied to investigate the epidemic foci, including their sources. A total of 6,206 HFRS cases and 59 related deaths were reported in Shandong Province. The virus carriage rates of the rodents Rattus norvegicus, Apodemus agrarius and Mus musculus were 10.24%, 6.31% and 0.27%, respectively. The phylogenetic analysis indicated that two novel viruses obtained from R. norvegicus in Anqiu City and Qingzhou City were dissimilar to the other strains, but closely related to strains previously isolated in northeastern China. Three epidemic foci were defined, two of which were derived from the Jining and Linyi epidemic foci, respectively, while the other was the residue of the Jining epidemic focus.

CONCLUSIONS/SIGNIFICANCE

The southeastern and central Shandong Province are current key HFRS epidemic foci dominated by A. agrarius and R. norvegicus, respectively. Our study could help local departments to strengthen prevention and control measures in key areas to reduce the hazards of HFRS.

Severe fever with thrombocytopenia syndrome can masquerade as hemorrhagic fever with renal syndrome

Background

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging viral hemorrhagic fever with a high fatality rate and high frequency of person-to-person transmission and is caused by SFTSV, a tick-borne Phlebovirus. Because SFTS has similar clinical manifestations and epidemic characters (such as spatial and temporal distributions) with hemorrhagic fever with renal syndrome (HFRS) in China, we reason that SFTS patients might be misdiagnosed as HFRS.

Methodology/principal findings

Acute-phase sera of 128 clinically diagnosed HFRS patients were retrospectively analyzed for Hantavirus IgM antibodies with ELISA. Hantavirus-negative patients’ sera were further analyzed for SFTSV IgM antibodies with ELISA. ELISA showed that 73 of 128 (57.0%) of clinically diagnosed HFRS patients were IgM antibody positive to Hantaviruses. Among the 55 Hantavirus-IgM negative patients, four (7.3%) were IgM antibody positive to SFTSV. The results indicated that the four SFTS patients were misdiagnosed as HFRS. The misdiagnosed SFTS patients had clinical manifestations common to HFRS and were unable to be differentiated from HFRS clinically.

Conclusions

Our study showed that SFTS patients could be clinically misdiagnosed as HFRS. The misdiagnosis of SFTS as HFRS causes particular concern because it may increase the risk of death of SFTS patients and person-to-person transmission of SFTSV without proper care for and isolation of SFTS patients.

SFTS were clinically misdiagnosed as HFRS. It could cause particular concern in China. Physicians could not rely heavily on the exposure history. Both SFTS and HFRS patients are treated based on the clinical diagnosis in China. Laboratory confirmation of both diseases is not performed in clinical hospitals and the patients’ blood was usually submitted to a local or provincial center for disease control and prevention. In most cases the confirmation diagnosis is to provide retrospective information rather than to guide clinical therapy. Therefore, physicians need to carefully differentiate SFTS and HFRS patients because the fatality of SFTS is much higher than HFRS and SFTS is easily spread from person to person by contacting infected blood or even through aerosol.

Effects of climate factors on hemorrhagic fever with renal syndrome in Changchun, 2013 to 2017

Hemorrhagic fever with renal syndrome (HFRS) is a rodent-borne disease caused by hantaviruses (HVs). Climate factors have a significant impact on the transmission of HFRS. Here, we characterized the dynamic temporal trend of HFRS and identified the roles of climate factors in its transmission in Changchun, China.Surveillance data of HFRS cases and data on related environmental variables from 2013 to 2017 were collected. A principal components regression (PCR) model was used to quantify the relationship between climate factors and transmission of HFRS.During 2013 to 2017, a distinctly declining temporal trend of annual HFRS incidence was identified. Four principal components were extracted, with a cumulative contribution rate of 89.282%. The association between HFRS epidemics and climate factors was better explained by the PCR model (F = 10.050, P <.001, adjusted R = 0.456) than by the general multiple regression model (F = 2.748, P <.005, adjusted R = 0.397).The monthly trends of HFRS were positively correlated with the mean wind velocity but negatively correlated with the mean temperature, relative humidity, sunshine duration, and accumulative precipitation of the different previous months. The study results may be useful for the development of HFRS preventive initiatives that are customized for Changchun regarding specific climate environments.

Dentin matrix protein 1 correlates with the severity of hemorrhagic fever with renal syndrome and promotes hyper-permeability of endothelial cells infected by Hantaan virus

Hantaviruses are the major causative agents of hemorrhagic fever with renal syndrome (HFRS) in humans, which is characterized by increased capillary permeability. Dentin matrix protein 1 (DMP1) has been shown to degrade components of the basal membrane and interendothelial junctions via matrix metalloproteinase-9. To study the changes of serum DMP1 in HFRS, we determined the concentration of DMP1 using sandwich enzyme-linked immunosorbent assay. We found that serum DMP1 concentrations increased significantly, and reached peak value during the oliguric phase and in the critical group in HFRS patients. Moreover, serum DMP1 concentrations were closely related to blood urea nitrogen, creatinine, cystatin C, and vascular endothelial growth factor (VEGF). We further explored the role of DMP1 in HTNV-infected human umbilical vein endothelial cells (HUVECs) model. Data from immunocytochemistry showed that VEGF and tumor necrosis factor-α (TNF-α) promoted the expression of DMP1 on HTNV-infected HUVECs. Results from transwell assays demonstrated that the permeability of HUVECs increased significantly after HTNV infection with the addition of DMP1, VEGF, and TNF-α. This study suggests that elevated DMP1 concentrations may be associated with disease stage, severity, and the degree of acute kidney injury. DMP1 is involved in the regulation of capillary permeability in HFRS caused by hantavirus infection.