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<TABLE class=formlayout id=apex_layout_271110100662109808 summary=""><TBODY><TR><TD noWrap align=right>Published Date</TD><TD noWrap align=left>05-AUG-2008</TD></TR><TR><TD noWrap align=right>Subject</TD><TD noWrap align=left>PRO/AH/EDR> Undiagnosed hem. disease - China (02): (SD), anaplasmosis</TD></TR></TBODY></TABLE>
UNDIAGNOSED HEMORRHAGIC DISEASE - CHINA (02): (SHANDONG), ANAPLASMOSIS************************************** *************************************A ProMED-mail post<http://www.promedmail.org>ProMED-mail is a program of theInternational Society for Infectious Diseases<http://www.isid.org>Date: Tue 5 Aug 2008From: Hans Troedsson <who.chn@wpro.who.int>The WHO [World Health Organization] China Office has had ongoing communications with the Ministry of Health China regarding "Undiagnosed hemorrhagic disease - China: (Shandong) RFI Archive Number 20080727.2300. The Chinese experts have completed an investigation into the incident. Four cases of human granulocytic anaplasmosis were identified in Wanjiakou village in Shandong province. The diagnosis was laboratory confirmed by PCR [polymerase chain reaction] and sequencing analysis.To our knowledge, the 1st case was a 43-year-old male farmer hospitalized on 18 Jun 2008 (with fever, leucopenia, and thrombocytopenia) and who died on 23 Jun 2008 despite treatment. The father of this patient was also identified with the disease, had onset of symptoms on 1 Jul 2008, and died on 10 Jul 2008. Two other cases were found in the same village on 2 and 5 Jul 2008. They recovered after being treated and were discharged from hospital on 13 and 14 Jul 2008 respectively. Active case finding has not identified additional cases.Anaplasmosis is a tick-borne disease, not known to spread by human-to-human transmission. China has lately strengthened its prevention and control measures as well as improved diagnosis and treatment guidelines for tick-borne diseases. The disease is not notifiable in China but has been recognized before in China as well as in other countries including the USA, several European countries, and recently in Canada.These are sporadic cases of anaplasmosis. The disease can be treated effectively [with] antibiotics. These cases of anaplasmosis do not pose an outbreak or epidemic threat. Further information may be provided by the Ministry of Health upon request.--Dr Hans TroedssonWorld Health Organization Representative to China<who.chn@wpro.who.int>[ProMED-mail thanks Dr Troedsson for his response to our request for information. In the original posting, the following is reported:"A man suddenly died from an unidentified disease in Wanjiakou Village, Xiaoguan Town, Wendeng City, Shandong Province. His entire body turned dark purple, and he bled from his mouth, nostrils, ears, and eyes just as he died.Shortly after the man died, 2 other men who [had] been in contact with him, died showing the same symptoms. Villagers who had left the village to work said "3 people died 10 days ago."It may well be the case that this initial description is inaccurate. Human granulocytic anaplasmosis (HGA) has a quite low case fatality rate especially in seemingly otherwise healthy people. A mortality rate of 2 out of 4 cases (50 percent) would be unusual for HGA as would be an apparent cluster.Mortality seems to be related to multiorgan failure and although a low platelet count may cause bleeding, the circumstances described in the initial posting are likely not due to a low platelet count. - Mod.LL][Background information on HGA in China is available on the Global Infectious Disease and Epidemiology Network (GIDEON) website (<http://www.gideononline.com>)."Seropositive ruminants have been documented in Xinjiang Uygur Autonomous Region area. (see ref 1 below)- Seropositive rodents have been documented in Jilin Province: Japanese field mouse (_Apodemus peninsulae_), Black-striped field mouse (_A. agrarius_) and Siberian chipmunk (_Tamias sibiricu_). (see ref 2 below)"Ehrlichial DNA (Anaplasma phagocytophilum) has been detected in _Ixodes persulcatus_ ticks from the Northeastern (ie, Lyme disease) region - Inner Mongolia and Heilongjiang Province. (see refs 3 and 4 below)- Infected I. persulcatus and Dermacentor silvarum have been detected in Jilin Province. (see ref 2 below)"Prevalence surveys: 8.82 percent of forest rodents in Jilin province, 1.64 percent in Helongjiang province and 0 percent in Inner Mongolia autonomous region (2007 publication) (see ref 5 below) 4.6 percent to 6.8 percent of _I. persulcatus_ in Jilin province (2003 to 2005 publications) (see refs 3 and 4 below) 14.1 percent of rodents captured from a mountainous area in southeastern China (Zhejiang Province, 2008 publication) (see ref 6 below)"Seroprevalence surveys: 8.8 percent of farm workers near Tianjin (2006) (see ref 7 below)."In Zhang et al's Rickettsial Seroepidemiology among Farm Workers, Tianjin, People's Republic of China. (see ref 7 below), the authors conclude that "human infections with these zoonotic bacteria are frequent and largely unrecognized." (The zoonotic bacteria and seroprevalence mentioned in the study are: _Anaplasma phagocytophilum_ (8.8 percent), _Coxiella burnetii_ (6.4 percent), _Bartonella henselae_ (9.6 percent), and _Rickettsia typhi_ (4.1 percent)). Since the investigation conducted in Shandong was active case searching and not a serosurvey of the general population to identify subclinical or very mild infections, it is possible that there were many such sub-clinical or very mild infections occurring which would markedly increase the denominator and thereby lower the observed case fatality rate observed in this current incident.For a map of China with geographic divisions see <http://www.lib.utexas.edu/maps/middle_east_and_asia/china_pol01.jpg>. Of note, Shandong province is contiguously with Hebei province to the north, where Tianjin is located -- one might conclude that a seroepidemiology of rural areas in Shandong province would lead to similar results as seen in the neighboring province.The interactive HealthMap/ProMED map of China can be accessed at <http://healthmap.org/promed?v=36.5,103.9,4> This map provides links to other recent ProMED-mail postings on events occurring in China and neighboring countries.Suggested references:1. Chahan B, Jian Z, Xuan X, Sato Y, et al. Serological evidence of infection of Anaplasma and Ehrlichia in domestic animals in Xinjiang Uygur Autonomous Region area, China. Vet Parasitol 2005 Dec 10;134(3-4):273-8.2. Cao WC, Zhan L, He J, Foley JE,et al. Natural Anaplasma phagocytophilum infection of ticks and rodents from a forest area of Jilin Province, China. Am J Trop Med Hyg 2006 Oct ;75(4):664-8.3. Zhao QM, Wu XM, Zhang PH, Li JM, et al. [Study on the coinfection of three tick-borne infectious diseases in China using polymerase chain reaction method] Zhonghua Liu Xing Bing Xue Za Zhi 2005 Jan ;26(1):9-13.4. Wen B, Cao W, Pan H. Ehrlichiae and ehrlichial diseases in China. Ann N Y Acad Sci 2003 Jun ;990():45-53.5. Zhan L, He J, Saren GW, Wu XM, et al. [Investigation on Anaplasma phagocytophilum infection in rodents from forest areas in northeastern China]. Zhonghua Liu Xing Bing Xue Za Zhi 2007 Feb ;28(2):157-9.6. Zhan L, Cao WC, De Vlas S, Xie SY, et al. A Newly Discovered Anaplasma phagocytophilum Variant in Rodents from Southeastern China. Vector Borne Zoonotic Dis 2008 May 9.7. Zhang L, Shan A, Mathew B, Yin J, et al. Rickettsial Seroepidemiology among Farm Workers, Tianjin, People's Republic of China. Emerg Infect Dis 2008 Jun ;14(6):938-940. [full article available at: <http://www.cdc.gov/eid/content/14/6/pdfs/938.pdf>]- Mod.MPP]
http://www.promedmail.org/pls/otn/f?..._ID:1000,73408</PRE>
UNDIAGNOSED HEMORRHAGIC DISEASE - CHINA (02): (SHANDONG), ANAPLASMOSIS************************************** *************************************A ProMED-mail post<http://www.promedmail.org>ProMED-mail is a program of theInternational Society for Infectious Diseases<http://www.isid.org>Date: Tue 5 Aug 2008From: Hans Troedsson <who.chn@wpro.who.int>The WHO [World Health Organization] China Office has had ongoing communications with the Ministry of Health China regarding "Undiagnosed hemorrhagic disease - China: (Shandong) RFI Archive Number 20080727.2300. The Chinese experts have completed an investigation into the incident. Four cases of human granulocytic anaplasmosis were identified in Wanjiakou village in Shandong province. The diagnosis was laboratory confirmed by PCR [polymerase chain reaction] and sequencing analysis.To our knowledge, the 1st case was a 43-year-old male farmer hospitalized on 18 Jun 2008 (with fever, leucopenia, and thrombocytopenia) and who died on 23 Jun 2008 despite treatment. The father of this patient was also identified with the disease, had onset of symptoms on 1 Jul 2008, and died on 10 Jul 2008. Two other cases were found in the same village on 2 and 5 Jul 2008. They recovered after being treated and were discharged from hospital on 13 and 14 Jul 2008 respectively. Active case finding has not identified additional cases.Anaplasmosis is a tick-borne disease, not known to spread by human-to-human transmission. China has lately strengthened its prevention and control measures as well as improved diagnosis and treatment guidelines for tick-borne diseases. The disease is not notifiable in China but has been recognized before in China as well as in other countries including the USA, several European countries, and recently in Canada.These are sporadic cases of anaplasmosis. The disease can be treated effectively [with] antibiotics. These cases of anaplasmosis do not pose an outbreak or epidemic threat. Further information may be provided by the Ministry of Health upon request.--Dr Hans TroedssonWorld Health Organization Representative to China<who.chn@wpro.who.int>[ProMED-mail thanks Dr Troedsson for his response to our request for information. In the original posting, the following is reported:"A man suddenly died from an unidentified disease in Wanjiakou Village, Xiaoguan Town, Wendeng City, Shandong Province. His entire body turned dark purple, and he bled from his mouth, nostrils, ears, and eyes just as he died.Shortly after the man died, 2 other men who [had] been in contact with him, died showing the same symptoms. Villagers who had left the village to work said "3 people died 10 days ago."It may well be the case that this initial description is inaccurate. Human granulocytic anaplasmosis (HGA) has a quite low case fatality rate especially in seemingly otherwise healthy people. A mortality rate of 2 out of 4 cases (50 percent) would be unusual for HGA as would be an apparent cluster.Mortality seems to be related to multiorgan failure and although a low platelet count may cause bleeding, the circumstances described in the initial posting are likely not due to a low platelet count. - Mod.LL][Background information on HGA in China is available on the Global Infectious Disease and Epidemiology Network (GIDEON) website (<http://www.gideononline.com>)."Seropositive ruminants have been documented in Xinjiang Uygur Autonomous Region area. (see ref 1 below)- Seropositive rodents have been documented in Jilin Province: Japanese field mouse (_Apodemus peninsulae_), Black-striped field mouse (_A. agrarius_) and Siberian chipmunk (_Tamias sibiricu_). (see ref 2 below)"Ehrlichial DNA (Anaplasma phagocytophilum) has been detected in _Ixodes persulcatus_ ticks from the Northeastern (ie, Lyme disease) region - Inner Mongolia and Heilongjiang Province. (see refs 3 and 4 below)- Infected I. persulcatus and Dermacentor silvarum have been detected in Jilin Province. (see ref 2 below)"Prevalence surveys: 8.82 percent of forest rodents in Jilin province, 1.64 percent in Helongjiang province and 0 percent in Inner Mongolia autonomous region (2007 publication) (see ref 5 below) 4.6 percent to 6.8 percent of _I. persulcatus_ in Jilin province (2003 to 2005 publications) (see refs 3 and 4 below) 14.1 percent of rodents captured from a mountainous area in southeastern China (Zhejiang Province, 2008 publication) (see ref 6 below)"Seroprevalence surveys: 8.8 percent of farm workers near Tianjin (2006) (see ref 7 below)."In Zhang et al's Rickettsial Seroepidemiology among Farm Workers, Tianjin, People's Republic of China. (see ref 7 below), the authors conclude that "human infections with these zoonotic bacteria are frequent and largely unrecognized." (The zoonotic bacteria and seroprevalence mentioned in the study are: _Anaplasma phagocytophilum_ (8.8 percent), _Coxiella burnetii_ (6.4 percent), _Bartonella henselae_ (9.6 percent), and _Rickettsia typhi_ (4.1 percent)). Since the investigation conducted in Shandong was active case searching and not a serosurvey of the general population to identify subclinical or very mild infections, it is possible that there were many such sub-clinical or very mild infections occurring which would markedly increase the denominator and thereby lower the observed case fatality rate observed in this current incident.For a map of China with geographic divisions see <http://www.lib.utexas.edu/maps/middle_east_and_asia/china_pol01.jpg>. Of note, Shandong province is contiguously with Hebei province to the north, where Tianjin is located -- one might conclude that a seroepidemiology of rural areas in Shandong province would lead to similar results as seen in the neighboring province.The interactive HealthMap/ProMED map of China can be accessed at <http://healthmap.org/promed?v=36.5,103.9,4> This map provides links to other recent ProMED-mail postings on events occurring in China and neighboring countries.Suggested references:1. Chahan B, Jian Z, Xuan X, Sato Y, et al. Serological evidence of infection of Anaplasma and Ehrlichia in domestic animals in Xinjiang Uygur Autonomous Region area, China. Vet Parasitol 2005 Dec 10;134(3-4):273-8.2. Cao WC, Zhan L, He J, Foley JE,et al. Natural Anaplasma phagocytophilum infection of ticks and rodents from a forest area of Jilin Province, China. Am J Trop Med Hyg 2006 Oct ;75(4):664-8.3. Zhao QM, Wu XM, Zhang PH, Li JM, et al. [Study on the coinfection of three tick-borne infectious diseases in China using polymerase chain reaction method] Zhonghua Liu Xing Bing Xue Za Zhi 2005 Jan ;26(1):9-13.4. Wen B, Cao W, Pan H. Ehrlichiae and ehrlichial diseases in China. Ann N Y Acad Sci 2003 Jun ;990():45-53.5. Zhan L, He J, Saren GW, Wu XM, et al. [Investigation on Anaplasma phagocytophilum infection in rodents from forest areas in northeastern China]. Zhonghua Liu Xing Bing Xue Za Zhi 2007 Feb ;28(2):157-9.6. Zhan L, Cao WC, De Vlas S, Xie SY, et al. A Newly Discovered Anaplasma phagocytophilum Variant in Rodents from Southeastern China. Vector Borne Zoonotic Dis 2008 May 9.7. Zhang L, Shan A, Mathew B, Yin J, et al. Rickettsial Seroepidemiology among Farm Workers, Tianjin, People's Republic of China. Emerg Infect Dis 2008 Jun ;14(6):938-940. [full article available at: <http://www.cdc.gov/eid/content/14/6/pdfs/938.pdf>]- Mod.MPP]
http://www.promedmail.org/pls/otn/f?..._ID:1000,73408</PRE>
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