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UNDIAGNOSED HEMORRHAGIC DISEASE - CHINA (02): (SHANDONG), ANAPLASMOSIS
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A ProMED-mail post
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International Society for Infectious Diseases
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Date: Tue 5 Aug 2008
From: 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 Troedsson
World 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]
[see also:
Undiagnosed hemorrhagic disease - China: (Shandong), RFI 20080727.2300
Hantavirus infection - Taiwan ex China (Inner Mongolia) 20080119.0249
Anaplasmosis, human granulocytic - Canada: 1st rep., (AB) 20080731.2352]
...................................mpp/ll/mj/mpp
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