UNDIAGNOSED HEMORRHAGIC DISEASE - CHINA: (SHANDONG), REQUEST FOR INFORMATION
****************************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Date: 27 Jul 2008
From: Stephen O. Cunnion
<scunnion@potomacinstitute.org>
I received the following email from Chuck Dolejs of the International
Association of Emergency Managers regarding a Sound of Hope web page
(<http://en.epochtimes.com/n2/china/strange-disease-kills-three-in-china-1742.html>)
updated [26 Jul 2008]. Has this outbreak been verified by authorities?
"China reported that approximately 20 days ago, 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 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. 6 or 7 more are being treated in
the Wendeng Central Hospital. People have been to the area to
investigate, but they are unable to classify the disease." Most people
outside of the village do not know about the illness. Their families
do not want people who have left the village to return.
"Reporters from Sound of Hope Radio Network (SOH) interviewed local
residents and staff from a health clinic. What follows are
transcripts from the recorded interviews. A male villager verified
that the disease broke out in the northern section of Wanjiakou
Village, and spread rather quickly. The SOH reporter then phoned the
Department of Health and Prevention of Contagious Diseases in Wendeng
City and Yantai City, Shandong Province using numbers published on
the official web sites. However, he was unable to talk with anyone,
as the line was either filled with static or the call was routed to a
wrong number announcement." [The actual details of the interviews are
available at the URL link provided above - Mod.MPP]
--
Stephen O. Cunnion, MD, PhD, MPH
Medical Director, National Security Health Policy Center
The Potomac Institute for Policy Studies
901 N. Stuart Street, Suite 200
Arlington, VA 22203
<scunnion@potomacinstitute.org>
[ProMED-mail would like to thank Dr. Stephen Cunnion for sending on
this information. As a reminder, it was he who sent ProMED-mail the
1st report on an outbreak of "atypical pneumonia" in Guangdong, China,
on 10 Feb 2003 that we posted and was the 1st public notification of
the early outbreaks of what was later named Severe Acute Respiratory
Sydrome (SARS) (see ProMED-mail posting Pneumonia - China
(Guangdong): RFI 20030210.0357 for this report).
Using the database of the Global Infectious Disease and Epidemiology
Network (GIDEON <http://gideononline.com>) to see possible etiologies
for a hemorrhagic fever syndrome in China, the most likely diagnosis
would be Old World hantavirus infection (57 percent probability),
followed by _Streptococcus suis_ infection (40 percent), leptospirosis
(1.8 percent) and Crimean-Congo hemorrhagic fever (CCHF -- less than
one percent probability).
According to the GIDEON database, hantaviruses are endemic in 28 of
the 32 provinces, with most cases occurring in the eastern and
northeastern provinces (where Shandong is located). Hantaan virus is
endemic to Hubei, Heilongjiang, Jiangxi, Jilin and Shanxi. (Fang LQ,
Li CY, Yang H, Wu XM, Yang H, Chen HX, Li XW, Cao WC [Using geographic
information system to study the association between epidemic areas and
main animal hosts of hemorrhagic fever with renal syndrome in China.]
Zhonghua Liu Xing Bing Xue Za Zhi 2004 Nov ;25(11):929-33.
- 52.2 percent of infections in Hubei are caused by Hantaan virus,
and 31.5 percent by Seoul virus.
- Most infections in Shandong provin
ce are caused by Seoul virus. (Wang ZQ, Wang YL, Fu JH, Zhao L, Sun
CY, Zhang XQ, Zhang YX, Fan SZ, Wang ND [Molecular analysis of
hantavirus isolated from Shandong province]. Zhonghua Shi Yan He Lin
Chuang Bing Du Xue Za Zhi 2003 Jun ;17(2):121-3.)
- Seoul virus was identified in humans and rodents (_Rattus
norvegicus_ and _Mus musculus_) in Beijing during 2003 to 2005. (Zuo
SQ, Zhang PH, Jiang JF, Zhan L, Wu XM, Zhao WJ, Wang RM, Tang F, Dun
Z, Cao WC. Seoul virus in patients and rodents from Beijing, China. Am
J Trop Med Hyg 2008 May ;78(5):833-7.
A new Puumala virus subtype, most closely related to strains from
Japan and South Korea, has been isolated from bank voles in Northeast
China. (2007 publication) (Tang LH, Zhang QF, Xiu MH, Gu GW, Bo S,
Yang XD, Liang MF, Li DX [Identification of a new Puumala hantavirus
subtype in rodents from China] Bing Du Xue Bao 2007 Jul ;23(4):320-5.
The abstract does not give any information about human infection by it.
ProMED-mail has reported on hantavirus outbreaks in China earlier this
year in Inner Mongolia (see Hantavirus infection - Taiwan ex China
(Inner Mongolia) 20080119.0249), and in prior years (see references
below)
According to the GIDEON database, CCHF has been reported from the
southwestern desert region in Xinjiang province and is referred to as
Xinjiang fever. Hence it would be a significant geographic change
were this outbreak to be due to CCHF. There is also mention that 10
to 20 percent of sheep, goats and cattle in Sichuan are seropositive
-- so movement of livestock from the southwest to other provinces may
very well move the disease geographically.
One should not forget the earlier major outbreaks of _Streptococcus
suis_ in China in 2005. A recurrence of the problem is possible.
It is noteworthy that according to the question and answer part of
the referred media report, there is mention that the cases to date
have been in predominantly in men, suggesting that exposure may well
be occupational, which places both hantavirus infection and
_Streptococcus suis_ as leading possibilities for the etiologic agent
for this outbreak. The outbreak is occurring in a rural zone where
there is a high likelihood of exposure of males to rodents and to the
porcine population during usual occupational activities in an
agricultural zone.
ProMED-mail would greatly appreciate more information from
knowledgeable sources in the region on this as yet unsubstantiated
report of a cluster of hemorrhagic-like illnesses with fatalities in
Shandong Province.
For a map of China with geographic divisions see
<http://www.lib.utexas.edu/maps/middle_east_and_asia/china_pol01.jpg>.
Of note, Shanjong province is contiguously north of Jiangsu province,
where there was an outbreak of 'epidemic hemorrhagic fever' in 2007,
which while the etiologic agent was not mentioned, was felt to most
likely be due to an Old World hantavirus infection (see prior
ProMED-mail postings Epidemic hemorrhagic fever - China
(Jiangsu) 20070113.0179 and Epidemic hemorrhagic fever - China
(Jiangsu) (02) 20070116.0206).
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. - Mod.MPP]
[Seoul virus occurs worldwide and is unlikely to be associated with a
localized outbreak in China. Puumala virus is prevalent throughout
northern Europe and middle Asia and is usually responsible for only
mild forms of hemorragic fever with renal syndrome (HFRS). - Mod.CP]
[see also:
Hantavirus infection - Taiwan ex China (Inner Mongolia) 20080119.0249
2007
----
Streptococcus suis, human - China (Guangdong) 20070726.2411
Streptococcus suis - China (Hong Kong) 20070517.1573
Streptococcus suis - China (Hong Kong)(02) 20070527.1707
Epidemic hemorrhagic fever - China (Jiangsu) 20070113.0179
Epidemic hemorrhagic fever - China (Jiangsu) (02) 20070116.0206
2006
----
Streptococcus suis, porcine, human, 2005 - China (... 20060411.1082
2005
----
Hemorrhagic fever - China (Inner Mongolia) 20050701.1863
Streptococcus suis, human - China (Hong Kong) 20050728.2196
Streptococcus suis, porcine, human - China 20050730.2217
Streptococcus suis, porcine, human - China (20) 20051024.3099
Streptococcus suis, porcine, human - China (Sichuan) (02) 20050728.2194
Streptococcus suis, porcine, human - China (Sichuan) 20050727.2179
2000
----
Hantavirus infection - China (Chongqing) (02) 20001121.2020
Hantavirus infection - China (Chongqing): alert 20001117.2008
Hantavirus infection - China: background 20001118.2015
Hantavirus infection - China: background (02) 20001126.2056
Hantavirus infection - China: background (03) 20001206.2127
1999
----
Strep. suis, human infection - China (Hong Kong) 19991009.1810
1998
----
Hantavirus infection - China (Hong Kong) 19980412.0670
Hemorrhagic fever, epidemic warning - China 19980905.1782
1997
----
Hemorrhagic fever with renal syndrome - S.E. Asia 19970408.0743]
...............................mpp/ejp/jw
****************************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Date: 27 Jul 2008
From: Stephen O. Cunnion
<scunnion@potomacinstitute.org>
I received the following email from Chuck Dolejs of the International
Association of Emergency Managers regarding a Sound of Hope web page
(<http://en.epochtimes.com/n2/china/strange-disease-kills-three-in-china-1742.html>)
updated [26 Jul 2008]. Has this outbreak been verified by authorities?
"China reported that approximately 20 days ago, 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 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. 6 or 7 more are being treated in
the Wendeng Central Hospital. People have been to the area to
investigate, but they are unable to classify the disease." Most people
outside of the village do not know about the illness. Their families
do not want people who have left the village to return.
"Reporters from Sound of Hope Radio Network (SOH) interviewed local
residents and staff from a health clinic. What follows are
transcripts from the recorded interviews. A male villager verified
that the disease broke out in the northern section of Wanjiakou
Village, and spread rather quickly. The SOH reporter then phoned the
Department of Health and Prevention of Contagious Diseases in Wendeng
City and Yantai City, Shandong Province using numbers published on
the official web sites. However, he was unable to talk with anyone,
as the line was either filled with static or the call was routed to a
wrong number announcement." [The actual details of the interviews are
available at the URL link provided above - Mod.MPP]
--
Stephen O. Cunnion, MD, PhD, MPH
Medical Director, National Security Health Policy Center
The Potomac Institute for Policy Studies
901 N. Stuart Street, Suite 200
Arlington, VA 22203
<scunnion@potomacinstitute.org>
[ProMED-mail would like to thank Dr. Stephen Cunnion for sending on
this information. As a reminder, it was he who sent ProMED-mail the
1st report on an outbreak of "atypical pneumonia" in Guangdong, China,
on 10 Feb 2003 that we posted and was the 1st public notification of
the early outbreaks of what was later named Severe Acute Respiratory
Sydrome (SARS) (see ProMED-mail posting Pneumonia - China
(Guangdong): RFI 20030210.0357 for this report).
Using the database of the Global Infectious Disease and Epidemiology
Network (GIDEON <http://gideononline.com>) to see possible etiologies
for a hemorrhagic fever syndrome in China, the most likely diagnosis
would be Old World hantavirus infection (57 percent probability),
followed by _Streptococcus suis_ infection (40 percent), leptospirosis
(1.8 percent) and Crimean-Congo hemorrhagic fever (CCHF -- less than
one percent probability).
According to the GIDEON database, hantaviruses are endemic in 28 of
the 32 provinces, with most cases occurring in the eastern and
northeastern provinces (where Shandong is located). Hantaan virus is
endemic to Hubei, Heilongjiang, Jiangxi, Jilin and Shanxi. (Fang LQ,
Li CY, Yang H, Wu XM, Yang H, Chen HX, Li XW, Cao WC [Using geographic
information system to study the association between epidemic areas and
main animal hosts of hemorrhagic fever with renal syndrome in China.]
Zhonghua Liu Xing Bing Xue Za Zhi 2004 Nov ;25(11):929-33.
- 52.2 percent of infections in Hubei are caused by Hantaan virus,
and 31.5 percent by Seoul virus.
- Most infections in Shandong provin
ce are caused by Seoul virus. (Wang ZQ, Wang YL, Fu JH, Zhao L, Sun
CY, Zhang XQ, Zhang YX, Fan SZ, Wang ND [Molecular analysis of
hantavirus isolated from Shandong province]. Zhonghua Shi Yan He Lin
Chuang Bing Du Xue Za Zhi 2003 Jun ;17(2):121-3.)
- Seoul virus was identified in humans and rodents (_Rattus
norvegicus_ and _Mus musculus_) in Beijing during 2003 to 2005. (Zuo
SQ, Zhang PH, Jiang JF, Zhan L, Wu XM, Zhao WJ, Wang RM, Tang F, Dun
Z, Cao WC. Seoul virus in patients and rodents from Beijing, China. Am
J Trop Med Hyg 2008 May ;78(5):833-7.
A new Puumala virus subtype, most closely related to strains from
Japan and South Korea, has been isolated from bank voles in Northeast
China. (2007 publication) (Tang LH, Zhang QF, Xiu MH, Gu GW, Bo S,
Yang XD, Liang MF, Li DX [Identification of a new Puumala hantavirus
subtype in rodents from China] Bing Du Xue Bao 2007 Jul ;23(4):320-5.
The abstract does not give any information about human infection by it.
ProMED-mail has reported on hantavirus outbreaks in China earlier this
year in Inner Mongolia (see Hantavirus infection - Taiwan ex China
(Inner Mongolia) 20080119.0249), and in prior years (see references
below)
According to the GIDEON database, CCHF has been reported from the
southwestern desert region in Xinjiang province and is referred to as
Xinjiang fever. Hence it would be a significant geographic change
were this outbreak to be due to CCHF. There is also mention that 10
to 20 percent of sheep, goats and cattle in Sichuan are seropositive
-- so movement of livestock from the southwest to other provinces may
very well move the disease geographically.
One should not forget the earlier major outbreaks of _Streptococcus
suis_ in China in 2005. A recurrence of the problem is possible.
It is noteworthy that according to the question and answer part of
the referred media report, there is mention that the cases to date
have been in predominantly in men, suggesting that exposure may well
be occupational, which places both hantavirus infection and
_Streptococcus suis_ as leading possibilities for the etiologic agent
for this outbreak. The outbreak is occurring in a rural zone where
there is a high likelihood of exposure of males to rodents and to the
porcine population during usual occupational activities in an
agricultural zone.
ProMED-mail would greatly appreciate more information from
knowledgeable sources in the region on this as yet unsubstantiated
report of a cluster of hemorrhagic-like illnesses with fatalities in
Shandong Province.
For a map of China with geographic divisions see
<http://www.lib.utexas.edu/maps/middle_east_and_asia/china_pol01.jpg>.
Of note, Shanjong province is contiguously north of Jiangsu province,
where there was an outbreak of 'epidemic hemorrhagic fever' in 2007,
which while the etiologic agent was not mentioned, was felt to most
likely be due to an Old World hantavirus infection (see prior
ProMED-mail postings Epidemic hemorrhagic fever - China
(Jiangsu) 20070113.0179 and Epidemic hemorrhagic fever - China
(Jiangsu) (02) 20070116.0206).
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. - Mod.MPP]
[Seoul virus occurs worldwide and is unlikely to be associated with a
localized outbreak in China. Puumala virus is prevalent throughout
northern Europe and middle Asia and is usually responsible for only
mild forms of hemorragic fever with renal syndrome (HFRS). - Mod.CP]
[see also:
Hantavirus infection - Taiwan ex China (Inner Mongolia) 20080119.0249
2007
----
Streptococcus suis, human - China (Guangdong) 20070726.2411
Streptococcus suis - China (Hong Kong) 20070517.1573
Streptococcus suis - China (Hong Kong)(02) 20070527.1707
Epidemic hemorrhagic fever - China (Jiangsu) 20070113.0179
Epidemic hemorrhagic fever - China (Jiangsu) (02) 20070116.0206
2006
----
Streptococcus suis, porcine, human, 2005 - China (... 20060411.1082
2005
----
Hemorrhagic fever - China (Inner Mongolia) 20050701.1863
Streptococcus suis, human - China (Hong Kong) 20050728.2196
Streptococcus suis, porcine, human - China 20050730.2217
Streptococcus suis, porcine, human - China (20) 20051024.3099
Streptococcus suis, porcine, human - China (Sichuan) (02) 20050728.2194
Streptococcus suis, porcine, human - China (Sichuan) 20050727.2179
2000
----
Hantavirus infection - China (Chongqing) (02) 20001121.2020
Hantavirus infection - China (Chongqing): alert 20001117.2008
Hantavirus infection - China: background 20001118.2015
Hantavirus infection - China: background (02) 20001126.2056
Hantavirus infection - China: background (03) 20001206.2127
1999
----
Strep. suis, human infection - China (Hong Kong) 19991009.1810
1998
----
Hantavirus infection - China (Hong Kong) 19980412.0670
Hemorrhagic fever, epidemic warning - China 19980905.1782
1997
----
Hemorrhagic fever with renal syndrome - S.E. Asia 19970408.0743]
...............................mpp/ejp/jw
