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Transmission routes of the virus causing viral hemorrhagic fever: Extreme precautions are prudent but high-quality evidence must be gathered

Published online by Cambridge University Press:  21 March 2019

Takuya Yamagishi*
Affiliation:
Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan
Kensaku Kakimoto
Affiliation:
Field Epidemiology Training Program, National Institute of Infectious Diseases, Tokyo, Japan
Ikuko Doi
Affiliation:
Field Epidemiology Training Program, National Institute of Infectious Diseases, Tokyo, Japan
Chiaki Kawakami
Affiliation:
Field Epidemiology Training Program, National Institute of Infectious Diseases, Tokyo, Japan
Tomoe Shimada
Affiliation:
Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan
Tamano Matsui
Affiliation:
Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan
Kazunori Oishi
Affiliation:
Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan
Masayuki Saijo
Affiliation:
Department of Virology I, National Institute of Infectious Diseases, Tokyo, Japan
*
Author for correspondence: Takuya Yamagishi, Email: tack-8@niid.go.jp
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Abstract

Type
Letter to the Editor
Copyright
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. 

To the Editor—Moon et alReference Moon, Lee and Jeon1 reported that airborne precautions might be needed when dealing with fatal cases of severe fever with thrombocytopenia syndrome (SFTS). For diseases with high fatality rates that lack specific and effective treatment, it is prudent to take a more extreme prevention strategy than that based on the documented transmission route.Reference Siegel, Rhinehart, Jackson and Chiarello2 One example in which this strategy is applied is Ebola virus disease, for which extreme precautions are taken.3 Given that SFTS virus (SFTSV) is a viral hemorrhagic fever virus that causes severe disease with a high fatality rate, we apply the same strategy to SFTS. Airborne precautions are recommended when healthcare providers conduct aerosol-generating procedures such as endotracheal intubation on a patient suspected of having SFTSV.

The transmission route of the disease treated under this prevention strategy should also be carefully examined during each outbreak. To date, airborne transmission of naturally occurring hemorrhagic fever viruses has not been documented.Reference Siegel, Rhinehart, Jackson and Chiarello2 The patient in the Moon et al article was a doctor wearing only a fluid-shield mask and gloves who performed endotracheal intubation on an SFTS patient and was infected with SFTS thereafter. Respiratory droplets are thought to be generated during endotracheal intubation, and protection of the eyes, nose, and mouth is recommended during the procedure in accordance with standard precautions.Reference Siegel, Rhinehart, Jackson and Chiarello2 Because the doctor in the article did not protect his eyes, it was possible that he acquired SFTSV through droplet contact with his eyes during the intubation procedure. However, this observation does not provide any evidence that SFTSV infects people through airborne transmission.

It is crucial to improve the level of precautions taken in acute-care settings in SFTS-endemic areas to prevent SFTSV transmission because most of the nosocomial transmissions of SFTSV are thought to occur before the diagnosis of the patient (infector) is confirmed as SFTS by the laboratory.Reference Gai, Liang and Zhang4Reference Jiang, Zhang and Jiang9 Standard precautions should be the norm for clinicians when they treat patients suspected of having SFTS. Between April 2013, when SFTS was designated as a notifiable disease in Japan, and December 2018, ∼400 cases have been reported in Japan.10 SFTS occurred sporadically in most patients, who were thought to have been infected with SFTSV through a tick bite during outdoor activities or by direct contact with a sick animal. To date, no case of healthcare-associated infection has been reported in Japan. However, we need to remain conscious of the risk of healthcare-associated infections.

We believe that strict adherence to standard and contact precautions can reduce the risk of nosocomial transmission of SFTSV and that taking airborne precautions as an extreme measure is required during aerosol-generating procedures. Additional evidence on the route of SFTSV transmission might guide the best precautions in the future.

Acknowledgements

We thank all the physicians and the staff at local public health centers and public health institutes who engage in surveillance activities in Japan.

Financial support

This report was funded by grants for the Research Program on Emerging and Re-emerging Infectious Diseases from the Japan Agency for Medical Research and Development.

Conflict of interest

All authors report no conflicts of interest relevant to this article.

References

Moon, J, Lee, H, Jeon, JH, et al. Aerosol transmission of severe fever with thrombocytopenia syndrome virus during resuscitation. Infect Control Hosp Epidemiol 2019:238241.CrossRefGoogle Scholar
Siegel, JD, Rhinehart, E, Jackson, M, Chiarello, L. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35:S65S164.CrossRefGoogle ScholarPubMed
World Health Organization. Personal protective equipment in the context of filovirus disease outbreak response: rapid advice guideline. World Health Organization website. https://apps.who.int/iris/handle/10665/251426. Published 2016. Accessed February 9, 2019.Google Scholar
Gai, Z, Liang, M, Zhang, Y, et al. Person-to-person transmission of severe fever with thrombocytopenia syndrome bunyavirus through blood contact. Clin Infect Dis 2012;54:249252.CrossRefGoogle ScholarPubMed
Kim, WY, Choi, W, Park, SW, et al. Nosocomial transmission of severe fever with thrombocytopenia syndrome in Korea. Clin Infect Dis 2015;60:16811683.CrossRefGoogle ScholarPubMed
Choi, SJ, Park, SW, Bae, IG, et al. Severe fever with thrombocytopenia syndrome in South Korea, 2013–2015. PLoS Negl Trop Dis 2016;10:e0005264.CrossRefGoogle ScholarPubMed
Shi, J, Wang, H, Huang, D, et al. A cluster of symptomatic and asymptomatic infections of severe fever with thrombocytopenia syndrome caused by person-to-person transmission. Am J Trop Med Hyg 2017;97:396402.Google Scholar
Gong, Z, Gu, S, Zhang, Y, et al. Probable aerosol transmission of severe fever with thrombocytopenia syndrome virus in southeastern China. Clin Microbiol Infect 2015;21:11151120.CrossRefGoogle ScholarPubMed
Jiang, XL, Zhang, S, Jiang, M, et al. A cluster of person-to-person transmission cases caused by SFTS virus in Penglai, China. Clin Microbiol Infect 2015;21:274279.CrossRefGoogle ScholarPubMed
Severe fever with thrombocytopenia syndrome, Japan. Japanese National Institute of Infectious Diseases website. https://www.niid.go.jp/niid/ja/sfts/3143-sfts.html [In Japanese.] Accessed February 9, 2019.Google Scholar
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