COURSE: TOPIC: FACULTY:

MEDICAL MICROBIOLOGY, MBIM 650/720 Zoonotic viruses II viruses with vertebrate vectors Dr. Margaret Hunt (Tel: 733-3293; e-mail: mhunt@med.sc.edu)

FALL 2001 LECTURE:63

REFERENCE: Murray et al., Microbiology, 3rd Ed., Chapter 58 (Rhabdoviruses, appropriate parts of chapters 60 (Bunya- and Hanta- viruses) and 64 (Filo- and Arenaviruses). WEB SITES: http://www.cdc.gov/ncidod/dvrd/rabies/introduction/intro.htm (rabies, excellent) http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5008a1.htm http://www.cdc.gov/ncidod/diseases/hanta/hps/index.htm (hantaviruses) TEACHING OBJECTIVES: Introduction to viral zoonoses. Brief overview of general features of rhabdoviruses, bunyaviruses (including hantaviruses), arenaviruses and filoviruses. Discussion of ecology, epidemiology and public health. Discussion of: rabies; rodent borne hemorrhagic fever and arenaviruses; hemorrhagic fever with renal syndrome, hantavirus pulmonary syndrome and hantaviruses; filovirus-associated hemorrhagic fevers and Ebola and Marburg viruses..

RABIES
G glycoprotein SPIKES

M protein lipid bilayer membrane

helical nucleocapsid (RNA plus N protein) polymerase (2 proteins)

Rabies virus: Single-stranded RNA virus, negative-sense, non-segmented genome. Member of the Lyssavirus genus (lyssa = frenzy) of the Rhabdovirus family. Virus is enveloped, the nucleocapsid has helical symmetry. TRANSMISSION: Usually obtained by a bite from an infected animal. In rare cases, has been transmitted by corneal transplant, or through contact of infected saliva with mucosal membranes or an open wound.. CDC: Inhalation of aerosolized rabies virus is also a potential non-bite route of exposure, but other than laboratory workers, most people are unlikely to encounter an aerosol of rabies virus. It has been suggested that people in infected bat caves may be exposed to aerosolized virus. Most bats are not infected.

PATHOGENESIS AND DISEASE: The virus replicates at the site of inoculation and then enters a peripheral nerve. It then travels along the nerve (retrograde axoplasmic flow) to the dorsal root ganglia. It replicates here and gains entry to the central nervous system and spreads to various parts of the brain. From here it can spread out via the nerves to various sites in the body (there is no viremia). The antibody response in an unvaccinated person is not seen until after the disease develops. If there is disease, it almost inevitably results in death. The incubation period is variable, from two weeks to eighteen months, with an average of about two months. The distance from the muscle to the CNS and the amount of virus in the wound play a role in determining the length of the incubation period. Since it takes a considerable period of time for the virus to get to the CNS, there is time for postexposure prophylaxis in rabies. If a humoral immune response can be raised by vaccination while the virus is in transit, this can prevent the disease.

Murray et al., Medical Microbiology

Symptoms can vary, and cases may often be misdiagnosed at first. There may be tingling or paresthesia at the site of the bite. In the initial phase there is fever, headache, malaise, anorexia. Later symptoms include: nausea, vomiting, myalgia, hydrophobia (in 20-50% of patients), and a variety of neurological symptoms such as confusion, hallucinations, seizures and paralysis. This is followed by coma, respiratory failure and death. Not all patients show all of these symptoms and the fact that rabies was the cause of the encephalitis may not be realized until post mortem.

DIAGNOSIS Neutralizing serum or cerebrospinal fluid antibodies in an unvaccinated person are diagnostic but usually are only detectable late in disease. A corneal impression or nuchal skin biopsy or brain biopsy can be examined for rabies antigen using a direct fluorescent antibody test. Saliva may be tested for rabies virus RNA by RT-PCR (reverse transcription-polymerase chain reaction). Eosinophilic, cytoplasmic inclusion bodies (Negri bodies) are seen in post-mortem staining of brain sections in ~50-80% of cases. They are typical of rabies, but the results need to be read by

someone experienced with rabies and there can be false positives - so all such results need to be confirmed by another method. There is a single serotype of rabies, however, there are subtle differences in nucleotide sequence between strains. The virus RNA is therefore amplified by RT-PCR and sequenced. This can give a clue as to the likely origin of the virus. EPIDEMIOLOGY

Usually transmitted by animal bite. Worldwide most cases arise from a dog bite. Canine rabies is prevalent in Latin America, Asia and Africa. In recent years (1990-2000) in the US the majority of cases (74%) have been associated with bat rabies; of the 8 remaining cases, all were from dog/coyote like-strains of virus and 7/8 of those were acquired outside the US. Many animals in the US are infected with rabies viruses, including raccoons (especially along the eastern seaboard states), skunks, coyotes, and foxes. Small rodents are rarely infected, but there have been cases reported, especially in woodchucks. Dogs, cats and cattle are potential vectors in the US immunization of pets has lessened the risk of pets acquiring rabies from wild animals. Bats also carry rabies, although most bats are not infected. Bats have very small, sharp teeth, and people who are bitten may not be aware of the bite, or not bother to do anything about it. With most bites from other rabid animals, the victim will get treatment because the bite is more serious and also because the animal appeared to behave in a suspicious fashion, the level of awareness seems to be lower for suspiciously behaving bats. Thus immunization of pets and prompt response for bites from most suspicious animals may explain why bat-transmission of rabies has been the predominant mode of transmission in recent years. In many cases of bat-associated rabies, there is no record of a bite. In some cases, the victim or their family may be aware that they handled a bat or that an oddly behaving bat was found in e.g. a bedroom (e.g. a bat which is active by day, is easily approached, is unable to fly, is in a room in a house or on a lawn). However, as mentioned above, if the victim is not sufficiently lucid to answer questions it may be difficult to obtain a history of bat contact since they may not have found the incident remarkable enough to mention to anyone. Human to human transmission has occurred in a few cases of corneal transplants (when it was not realized that the encephalitis was due to rabies). This has led to stricter criteria in screening of potential donors for encephalitis so that those who might have rabies (or Creutzfeld-Jakob

disease) are not accepted. Apart from these cases, no human-human spread of the disease has ever been documented.

PREVENTION AND TREATMENT OF A PERSON WHO MAY HAVE BEEN EXPOSED The wound is immediately and thoroughly washed with soap and water, then treated with 40-70% ethyl alcohol or an antiseptic such as benzyl ammonium chloride. The State Health authorities should be promptly informed. The risk of exposure to rabies and whether prophylactic treatment should be given are determined in consultation with the State Health Department. If the animal is available, the brain is examined for rabies virus antigen by fluorescent antibody. (In some cases, if the bite was from a domesticated cat or dog, the animal may be kept under close observation). Post-exposure prophylaxis Rabies vaccine. This is an inactivated vaccine and is strongly immunogenic. It is grown in human diploid cells or rhesus monkey lung cells and is more potent and has fewer side effects than the vaccine used in the early 1980s. A purified chick embryo cell grown vaccine is also available. The vaccine is administered as a series of injections over a 4-week period. Human rabies immunoglobulin (HRIG). HRIG is prepared from the plasma of hyperimmune donors. Up to half of the recommended dose is infiltrated into the wound area if possible. The remainder is given as an intramuscular injection. A separate syringe and a separate site are used for the HRIG and the vaccine so that the HRIG does not neutralize the vaccine. So far there has never been a case of someone who received post-exposure prophylaxis in the US developing rabies. Pre-exposure prophylaxis People at risk for rabies infection may be vaccinated as a preventive measure. Such individuals include rabies-laboratory workers; certain people in areas with enzootic rabies who are at risk for exposure to rabid animals: veterinarians and their staff, wildlife control workers, spelunkers; travelers who will be spending more than a month in areas with enzootic rabies. People at high risk for exposure to rabid animals should have regular serologic testing and booster vaccinations when necessary. If a vaccinated person is exposed to rabies, they still need to get post-exposure prophylaxis, but the number of post-exposure vaccination shots is reduced and HRIG is not used. TREATMENT There is no specific anti-viral treatment once symptoms develop. Intensive supportive care is given. However, there have only ever been three cases of documented recovery from rabies.

VIRAL DISEASES TRANSMITTED BY RODENTS

FAMILY ENVELOPE yes SYMMETRY helical GENOME ssRNA ambi-sense segmented

RODENT BORNE

yes
Hantavirus genus

helical

ssRNA (-ve) segmented

ARENAVIRUS FAMILY
VIRUS Lassa Machupo Junin Whitewater Arroyo DISEASE Lassa fever (HF) Bolivian HF Argentine HF Whitewater Arroyo HF OCCURRENCE Africa South America South America Western US

HF=hemorrhagic fever All of the above viruses have a rodent vector (there are other disease-associated arenaviruses). The arenavirus-associated hemorrhagic fevers have a high case-fatality rate (5-35%). The arenaviruses seem to easily establish persistent infections in certain rodents, which get a viruria. Humans are thought to acquire infection from contact with rodent urine contaminated materials. Disease in humans: dehydration, hemoconcentration, hemorrhage, shock syndrome, cardiovascular collapse. Recently (1999-2000) there have been reports of three deaths apparently due to a North American arenavirus (Whitewater Arroyo). It is not clear if there are other unrecognised cases of this virus or what the case fatality rate is.

BUNYAVIRUS FAMILY HANTAVIRUS GENUS

i) Associated with hemorrhagic fever with renal syndrome (HFRS) Korean hemorrhagic fever has a case-fatality rate of about 7%, other members of the hantaviruses which cause HFRS (hemorrhagic fever with renal syndrome) tend to have a lower fatality rate. Transmission appears to be via inhalation of, or contact with, rodent excreta.

ii) Associated with severe pulmonary syndrome A newly recognized (1993) group of hantaviruses in North and South America are transmitted by rodents (by inhalation or contact with excreta) and cause Hantavirus Pulmonary Syndrome (HPS) rather than hemorrhagic fever. These hantavirus pulmonary syndrome viruses have a high case fatality rate of ~40%. The viruses are widely distributed throughout the US but relatively rarely cause human disease - about 280 known cases so far in the US. Initial symptoms often include fever, myalgia, nausea, vomiting and a cough, this may progress to dizziness and shortness of breath and then acute respiratory distress. There are a several hantaviruses which have been associated with this syndrome, one of the best known of the US HPS-associated viruses is Sin Nombre virus.
NAME Korean HFRS TYPE OF DISEASE hemorrhagic fever with renal syndrome (HFRS) hemorrhagic fever with renal syndrome hantavirus pulmonary syndrome OCCURRENCE S.E.Asia

HFRS

Europe, Asia

Hantavirus pulmonary syndrome (HPS)

North and South America

VIRAL DISEASES IN WHICH RESERVOIR AND VECTOR ARE UNCLEAR

VECTOR UNKNOWN

FAMILY

ENVELOPE SYMMETRY

GENOME

yes

helical

ssRNA (-ve)

Ebola and Marburg viruses are filoviruses and cause hemorrhagic fevers. The case-fatality rate can be as high as 60-70% for certain strains of these viruses. These viruses occur in Africa, but the natural reservoir is unknown. They occasionally infect humans, but the means by which this occurs is usually not clear. Patients have severe hemorrhages and there is a lot of virus present, so stringent barrier nursing techniques are needed to prevent further spread. There have been a few cases where humans have been infected by apparently healthy laboratory monkeys.