National CDC protocol identifies characteristics associated with Heartland virus disease
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Testing for Heartland virus disease should be part of the evaluation for patients who have an acute febrile illness with either leukopenia or thrombocytopenia that cannot explained by another condition or when a tick-borne disease is suspected, but there was no improvement after appropriate treatment, according to a review of the virus’s epidemiology.
“CDC implemented a national protocol to evaluate patients for Heartland virus disease anywhere in the United States from June 2013 to December 2017,” J. Erin Staples, MD, PhD, of the CDC’s Arboviral Diseases Branch, told Healio. “Some of the main objectives of the evaluation were to more clearly understand where this novel virus is capable of causing human disease, define the signs and symptoms of the disease and evaluate risk factors for infection.”
Heartland virus disease is a novel phlebovirus that was initially isolated in 2009 from two individuals in northwestern Missouri who had been hospitalized for acute-onset febrile illness with fatigue, anorexia, diarrhea, leukopenia and thrombocytopenia, according to the paper in Open Forum Infectious Diseases. It was first described as a human pathogen in 2012.
Staples and colleagues assessed individuals aged 12 years and older whose clinicians contacted state health departments or CDC about testing for Heartland virus infections and were screened for recent onset of fever with leukopenia and thrombocytopenia. A questionnaire was used to gather data on demographics, risk factors and signs and symptoms of the disease. Blood samples were tested for the presence of Heartland virus disease RNA and neutralizing antibodies.
Results of the study demonstrated that, of the 85 individuals enrolled and tested, 16 (19%) showed evidence of acute Heartland virus infection, one (1%) had past infection and 68 (80%) had no infection. Among those with acute Heartland virus disease, 12 (75%) were men, the median age was 71 years and the majority of individuals reported fatigue, anorexia, nausea, headache, confusion, arthralgia or myalgia.
“We identified cases in a broader geographic range than previously described for Heartland virus disease studies,” Staples added. “Residents from 23 states participated in the current study. Patients who tested positive for Heartland virus were residents of seven states, mostly in the southeast and central US, including Arkansas, Indiana, Kansas, Kentucky, Missouri, North Carolina and Oklahoma.”
Most patients with Heartland virus disease (88%) were hospitalized, according to the study results. Two of these patients died.
“The case-fatality rate for Heartland virus disease is likely lower than what was identified in our study. Our participants were often referred for Heartland virus disease testing only after treatment with antibiotics had failed to improve their condition and another etiology had not been identified as the source of their illness,” Staples said. “All deaths from Heartland virus disease identified to date, including those in this study, have been in males over age 60 years, with death occurring 2 to 3 weeks after their illness onset from multi-system organ failure. All those who died had histories of multiple underlying medical conditions.”
The study also found that 14 patients (88%) reported an attached tick in the 2 weeks before illness onset. Individuals infected with Heartland virus were significantly older (P < .001) and more likely to report an attached tick (P = .03) than uninfected individuals.
“Health care providers should consider Heartland virus disease testing for patients who have a fever with either lower than normal counts of white blood cells (leukopenia) or lower than normal counts of platelets (thrombocytopenia) not explained by another condition or who were suspected of having another tick-borne disease and did not improve following treatment,” Staples said. “Because there are no treatments for the disease, health care providers should discuss with their patients ways to prevent becoming infected, such as using insect repellents, wearing long sleeves and pants, avoiding bushy and wooded areas and performing tick checks after spending time outdoors.”
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