LETTERS demonstrated enhanced entry into References Echinococcosis, renal epithelial cells (10). In our stud- 1. Ksiazek TG, Erdman D, Goldsmith CS, , ies, we did not find enhanced virus Zaki SR, Peret T, Emery S, et al. A novel replication in the respiratory tract of coronavirus associated with severe acute To the Editor: Ningxia is the respiratory syndrome. N Engl J Med. vaccinated mice upon SARS-CoV smallest provincial autonomous challenge. However, since mice are a 2003;348:1953–66. 2. Yang ZY, Kong WP, Huang Y, Roberts A, region on the Plateau in central model of SARS-CoV infection but Murphy BR, Subbarao K, et al. DNA vac- China, with a population of ≈5.5 mil- not disease, the issue of disease cine induces SARS coronavirus neutraliza- lion persons composed of 35 ethnic tion and protective immunity in mice. enhancement will have to be careful- and various religious groups. The nat- ly evaluated if and when an appropri- Nature. 2004;428:561–4. 3. Bisht H, Roberts A, Vogel L, Bukreyev A, ural environmental conditions and ate animal model in which this phe- Collins PL, Murphy BR, et al. Severe acute socioreligious ethnic status in nomenon can be demonstrated respiratory syndrome coronavirus spike Ningxia, particularly the southern protein expressed by attenuated vaccinia becomes available. region, are conducive to sheep farm- In summary, an inactivated SARS- virus protectively immunizes mice. Proc Natl Acad Sci U S A. 2004;101:6641–6. ing, an important part of the agricul- CoV vaccine, produced with a tech- 4. Bukreyev A, Lamirande EW, Buchholz UJ, tural economy. Both cystic echinococ- nology that has a safety record estab- Vogel LN, Elkins WR, St Claire M, et al. cosis (CE) and alveolar echinococco- Mucosal immunisation of African green lished by immunizing hundreds of sis (AE) (1) are endemic in the north- millions of persons, protects mice monkeys (Cercopithecus aethiops) with an attenuated parainfluenza virus expressing west part of China; high prevalences from challenge with SARS-CoV. The the SARS coronavirus spike protein for the have been reported in several vaccine adjuvanted with MF59 elicits prevention of SARS. Lancet. provinces (1), including (2,3) 2004;363:2122–7. neutralizing antibodies (titer 1:91) and the Uigur Autonomous after only 2 doses. We conclude that 5. Song HC, Seo M-Y, Stadler K, Yoo BJ, Choo Q-L, Coates S, et al. Synthesis and Region (4). Little information is avail- the vaccine described here has desir- characterization of a native, oligomeric able about the extent of human able properties, and our data support form of recombinant severe acute respirato- echinococcosis in Ningxia; this is the ry syndrome coronavirus spike glycopro- further development and plans for first report of a provincial investiga- clinical trials. tein. J Virol. 2004;78:10328–35. 6. Podda A, Del Giudice G. MF59-adjuvanted tion for both human CE and AE there. vaccines: increased immunogenicity with We conducted a retrospective sur- Acknowledgments an optimal safety profile. Expert Rev vey of clinical records from 7 local This study was supported by the Vaccines. 2003;2:197–203. 7. Takasuka N, Fujii H, Takahashi Y, Kasai M, county hospitals and 4 other hospitals Fonds der Chemischen Industrie, the 6th Morikawa S, Itamura S, et al. A subcuta- in to determine the epidemi- Framework Program of the European neously injected UV-inactivated SARS ology of human echinococcosis in Commission (FP6-511065), and Chiron coronavirus vaccine elicits systemic southern Ningxia. All surgical and Vaccines. humoral immunity in mice. Int Immunol. 2004;16:1423–30. clinical records were checked, and 8. Subbarao K, McAuliffe J, Vogel L, Fahle G, diagnoses were confirmed based on Konrad Stadler,*1 Fischer S, Tatti K, et al. Prior infection and imaging, surgical reports, and Anjeanette Roberts,†1 passive transfer of neutralizing antibody histopathologic reports. Data concern- prevent replication of severe acute respira- 1 Stephan Becker,‡ Leatrice Vogel,† tory syndrome coronavirus in the respirato- ing age, sex, domicile, ethnicity, occu- Markus Eickmann,‡ ry tract of mice. J Virol. 2004;78:3572–7. pation, year of diagnosis, cyst or Larissa Kolesnikova,‡ 9. Vennema H, de Groot RJ, Harbour DA, lesion numbers and anatomical loca- Hans-Dieter Klenk,‡ Dalderup M, Gruffydd-Jones T, Horzinek tion, type and duration of MC, et al. Early death after feline infectious Brian Murphy,† Rino Rappuoli,* peritonitis virus challenge due to recombi- anthelminthic treatment (if given), Sergio Abrignani,* nant vaccinia virus immunization. J Virol. and the nature and number of surger- and Kanta Subbarao† 1990;64:1407–9. ies performed for echinococcosis 10. Yang ZY, Werner HC, Kong WP, Leung K, *Chiron Vaccines, Siena, Italy; †National were recorded for each confirmed CE Traggiai E, Lanzavecchia A, et al. Evasion Institutes of Health, Bethesda, Maryland, of antibody neutralization in emerging and AE patient. USA; and ‡Institut für Virologie, Marburg, severe acute respiratory syndrome coron- From 1985 to 2002, a total of Germany aviruses. Proc Natl Acad Sci U S A. 2005; 2,216 cases of echinococcosis were 102:797–801. recorded, most of which were due to CE (96%). The incidence of com- Addresses for correspondence: Sergio bined CE and AE from 1994 to 2001 Abrignani, Chiron Vaccines, Via Fiorentina 1, was 7/100,000 persons for southern 53100 Siena, Italy; fax: 39-0577-243-564; 1These authors contributed equally to this Ningxia, compared with 1/100,000 work. email: [email protected] persons for Yinchuan in the north

1314 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 11, No. 8, August 2005 LETTERS

(Table). Human AE cases were report- significant differences in echinococ- rent study suggest that disease trans- ed only from the 3 southern counties cosis case numbers between men and mission was more pronounced 10–15 of Xiji, Haiyuan, and ; CE women (p<0.05). Farm laborers years earlier. The landscape of woods cases occurred throughout Ningxia, accounted for 66.1% (1,464/2,216) of and scrub cover was greater then, with a mixed endemic focus for both cases, students 12.4% (275/2,216), domestic sheep and dog populations human CE and AE in the south. A workers and self-employed 5.2% were larger, and red fox and rodent variable distribution of AE and CE (116/2,216), village leaders 4.8% species densities were likely higher, cases from 1994 to 2001 was evident (106/2,216), teachers and housewives providing optimal transmission condi- from hospital records. Both AE and 0.9% (21/2,216), butchers 0.2% tions for both Echinococcus granulo- CE were recorded in Xiji (6/100,000 (4/2,216), and others 0.1%. A compar- sus and E. multilocularis. persons), Guyuan (5/100,000 per- ison of the ethnic composition ratio The incidence data (2001) for sons), and Haiyuan (11/100,000 per- (5) with an average incidence from human CE and AE are likely underes- sons) counties. CE incidences for 1994 to 2001 showed a substantial timated for several reasons. Access to Tongxin (13/100,000 persons) and difference between the Hui and Han medical treatment for villagers is Pengyang (5/100,000 persons) were nationalities in Yinchuan, Haiyuan, problematic and many asymptomatic substantially higher than for Longde and Pengyang, and for Ningxia as a cases (6) would be excluded. An age (0.5/100,000 persons) and Jingyuan whole. No substantial difference was and sex bias also exists, as generally (0.15/100,000 persons). This hetero- shown in Longde, Tongxin, Guyuan, older persons and women receive geneous distribution of echinococco- and Xiji for the 2 ethnic groups by most of the limited medical attention. sis may reflect different patterns of incidence risk ratios with 95% confi- Furthermore, the high surgical costs parasite transmission in different dence intervals (Table). for treatment (CE and AE), especially areas of Ningxia. CE and AE inci- Radical surgery to remove CE in the past 10 years, coupled with dence (Table) were compared for cysts was performed for 83.3% of poor economic development, preclude 1994 and 2001 by chi-square test. patients; only 7.3% of patients access to treatment in many rural Apart from a substantial increase in received combined albendazole or communities. Because abdominal Haiyuan (p<0.05) and a substantial mebendazole chemotherapy pre- and ultrasound examinations for CE and decrease in Xiji (p<0.05), no other post-surgery. Recurrences of CE cysts AE can identify clinically silent infec- substantial incidence changes were that required surgery were high tions (7,8), comprehensive communi- apparent (Table). (30%), suggesting inadequate surgical ty-based studies are needed to identi- Patients’ ages ranged from 1 to 80 and medical care. Most AE patients fy asymptomatic or early-stage cases. years for men and from 3 to 77 years received only chemotherapy treat- Our study provides accurate data for women (mean age 35.7 years). ment and were at an advanced stage of to determine the true prevalence and The patient sex ratio was 0.72 (916 infection. incidence of CE and AE, which con- men, 1,268 women), whereas the pop- The retrospective data of human tributes to better treatment outcomes. ulation sex ratio was 1.05, indicating AE and CE infection rates in the cur- These data can help determine the

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 11, No. 8, August 2005 1315 LETTERS reasons for the heterogeneity of dis- 5. Qu Y, Sun ZW. Atlas of Ningxia Hui granulomalike rheumatoid nodules. I ease distribution in Ningxia to better Autonomous Region. Ying S, editor. did a PubMed search using “rheuma- Yinchuan: Publishing House of Xi’an prepare for future echinococcosis Atlas; 2000. p. 90–130. toid nodule in the brain” and 7 articles control strategies throughout the 6. Craig PS, Rogan MT, Allan JC. Detection, were found (2,3). A “rheumatoid region. screening and community epidemiology of endarteritis” search found 25 articles. taeniid cestode zoonoses: cystic echinococ- Heckman et al. failed to exclude or cosis, alveolar echinococcosis and neuro- Acknowledgments cysticercosis. Adv Parasitol. 1996;38: discuss this possibility. We thank Gail Williams for help with 169–250. Second, M. neoaurum is a rare statistical analysis. 7. Macpherson CN, Kachani M, Lyagoubi M, environmental mycobacterium that Berrada M, Shepherd M, Fields PF, et al. grows in <2 days on sheep blood agar This work was supported in part by Cystic echinococcosis in the Berber of the and is not difficult to culture. As the Ningxia Medical College, the University Mid Atlas mountains, Morocco: new insights into the natural history of the dis- authors stated, there have been 8 of Queensland, and an NIH/NSF Ecology ease in humans. Ann Trop Med Parasitol. reports of this organism, 7 isolated of Infectious Diseases ‘Transech’ project 2004;98:481–90. from blood and 1 from urine. The on echinococcosis. 8. Macpherson CN, Bartholomot B, Frider B. Application of ultrasound in diagnosis, blood isolates were associated with treatment, epidemiology, public health and either central venous catheter or intra- Yu Rong Yang,*† Tao Sun,† control of Echinococcus granulosus and E. venous drug use. Thus, M. neoaurum Zhengzhi Li,† Xiuping Li,† multilocularis. Parasitology. 2003;127 is of low virulence and unlikely to Rui Zhao,† Li Cheng,‡ Pan,§ (Suppl):S21–35. cause spontaneous infection in tissue Philip S. Craig,¶ unless inoculated accidentally, per- Address for correspondence: Donald P. Dominique A. Vuitton,# haps. Third, polymerase chain reac- McManus, Molecular Parasitology Laboratory, and Donald P. McManus* tion (PCR) is exquisitely sensitive and Queensland Institute of Medical Research, 300 *Queensland Institute of Medical prone to contamination. The problem Herston Road, Brisbane, Queensland 4006, Research, Brisbane, Queensland, is worse when bacterial DNA is Australia; †Ningxia Medical College, Australia; fax: 61-7-3362-0104; email: donM@ amplified by using highly conserved Ningxia Hui Autonomous Region, China; qimr.edu.au ‡The Second Provincial Hospital of Ningxia primers. The PCR reagents, from the Hui Autonomous Region, Ningxia, China; § Taq polymerase (of bacterial origin) Hospital, Xiji, Ningxia Hui to water, contain sufficient, despite Autonomous Region, China; ¶University of minute quantity, bacterial DNA to be Salford, Salford, United Kingdom; and #WHO Collaborating Centre for Prevention amplified (4). Although direct and Treatment of Human Echinococcosis, sequencing of the amplicon is often Besancon, France blurry because of its low quantity and Mycobacterium mixed content, when cloned, each References neoaurum amplicon may be ligated to the vector and proliferates and gets sequenced 1. Vuitton DA, Zhou H, Bresson-Hadni S, Contamination Wang Q, Piarroux M, Raoul F, et al. later. Epidemiology of alveolar echinococcosis To the Editor: In reviewing Therefore, I believe the presence with particular reference to China and “Rapidly Progressive Dementia due of M. neoaurum DNA, not the organ- Europe. Parasitology. 2003;127 ism itself, represented contamination. Suppl:S87–107. to Mycobacterium neoaurum 2. Craig PS, Giraudoux P, Shi D, Bartholomot Meningoencephalitis,” by Heckman Generally, drawing cause-disease B, Barnish G, Delattre P, et al. An epidemi- et al. (1), I found, contrary to the conclusion based on PCR sequencing ological and ecological study of human authors’ conclusion, that M. neoau- needs vigilance to satisfy the modi- alveolar echinococcosis transmission in fied Koch postulates (5). south Gansu, China. Acta Trop. rum was more likely a contaminant 2000;77:167–77. than a cause. First, within the granulo- 3. Bai Y, Cheng N, Jiang C, Wang Q, Cao D. matous brain lesions, the strongest Xiang Y. Han* Survey on cystic echinococcosis in evidence for the authors’ conclusion, *University of Texas, Houston, Texas, USA Tibetans, West China. Acta Trop. 2002;82:381–5. no acid-fast bacilli were isolated or References 4. Wang YH, Rogan MT, Vuitton DA, Wen H, identified on special stains; thus, the Bartholomot B, Macpherson CN, et al. Koch postulates were not satisfied. 1. Heckman GA, Hawkins C, Morris A, Cystic echinococcosis in semi-nomadic Rather, the lesions were likely Burrows LL, Bergeron C. Rapidly progres- pastoral communities in north-west China. rheumatoid nodules. Longstanding sive dementia due to Mycobacterium Trans R Soc Trop Med Hyg. neoaurum meningoencephalitis. Emerg 2001;95:153–8. rheumatoid arthritis commonly causes Infect Dis. 2004;10:924–7.

1316 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 11, No. 8, August 2005