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A Case-Control Study of Risk Sources for Severe Fever with Thrombocytopenia Syndrome in Hubei Province, China

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A Case-Control Study of Risk Sources for Severe Fever with Thrombocytopenia Syndrome in Hubei Province, China International Journal of Infectious Diseases 55 (2017) 86–91 Contents lists available at ScienceDirect International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid A Case-control Study of Risk Sources for Severe Fever with Thrombocytopenia Syndrome in Hubei Province, China a,1 a,1 a a a a Xuesen Xing , Xuhua Guan , Li Liu , Junqiang Xu , Guoming Li , Jianbo Zhan , a a a a a b Gongping Liu , Xiaoqing Jiang , Xingfu Shen , Yongzhong Jiang , Yang Wu , Hao Zhang , c d a a a, Jing Huang , Fan Ding , Sha Sha , Man Liu , Faxian Zhan * a Hubei Provincial Center for Disease Control and Prevention, Wuhan,China. No. 6 north Zhuodaoquan Road, Hongshan District, 2 Wuhan City, Hubei Province, China b 3 Yichang City Center for Disease Control and Prevention, Yichang, China c 4 Enshi County Center for Disease Control and Prevention, Enshi, China d 5 Chinese Center for Disease Control and Prevention, Beijing, China A R T I C L E I N F O A B S T R A C T Article history: Background: Severe fever with thrombocytopenia syndrome (SFTS), an emerging infectious disease Received 20 November 2016 caused by a novel bunyavirus, was discovered in rural areas of Central China in 2009. Received in revised form 3 January 2017 Methods: A case-control study based on hospital data was applied to detect the potential risk sources for Accepted 5 January 2017 SFTS in SFTS-endemic counties in Hubei Province. Cases were defined as hospitalized SFTSV confirmed Corresponding Editor: Eskild Petersen, patients. Controls were randomly selected from non-SFTSV patients in the same hospital ward within Aarhus, Denmark 2 weeks of inclusion of the cases, and they were matched by age (+/À 5 years) and gender according to 1:2 matching condition. Keywords: Results: 68 cases and 136 controls participated in this study. In multivariate analysis, “Contact with cattle case-control tick” was the major risk source (Conditional Logistic Regression OR-MH = 8.62, 95% CI = 1.79-41.51), severe fever with thrombocytopenia syndrome outdoor activities and working in weeds or hillside fields could increase risk of cattle tick contact and risk factors SFTS infection (Conditional Logistic Regression OR-MH = 8.82, 95% CI = 1.69-46.05, P value = 0.01). tick exposure Conclusion: Our results suggested cattle might be dominant hosts in SFTS-endemic regions in Hubei cattle tick Province, which provided clues to transmission mechanism of “vectors, host animals, and humans”, thus endemic more effectively preventing and controlling the disease. © 2017 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). Introduction 23 provinces, of which 2750 (51.4%) were lab-confirmed cases. Henan, Shandong, Hubei, Anhui, Liaoning, Zhejiang, and Jiangsu Severe Fever with Thrombocytopenia Syndrome (SFTS) is a reported 99.3% of those lab-confirmed cases. The fatality rate of the 4 newly emerging infectious disease caused by the SFTS virus, a lab-confirmed cases was 7.9%. Furthermore, SFTS has also been 1,2 5–7 genera in the family Bunyaviridae. Its major clinical symptoms recognized in Japan, South Korea, and the United States. In are fever, thrombocytopenia, gastrointestinal symptoms, and recent years, it has become an increasingly important global health leukocytopenia. SFTS was first reported in the rural areas of threat. Central China’s Hubei and Henan Provinces in 2009. with a case- The epidemic SFTS season appears to be between April and 3 fatality rate of up to 30%. During 2011 and 2014, 5352 suspected, October, and its peak occurs from May to July. The seasonal probable, and lab-confirmed SFTS cases were reported in distribution of SFTS cases is synchronous with the ecological habits 1–4 of ticks. Most (88.3% of) SFTS cases involved peasants living in wooded or hilly areas or working in the fields. People between the 4 * Corresponding author. Tel.: +86 027 87652061. ages of 50 and 74 years accounted for 67.6% of all cases. Some – E-mail address: [email protected] (F. Zhan). 1 4,8 patients with an SFTS diagnosis reported a history of tick bite. 1 These authors contributed equally to this work: Xuesen Xing, Xuhua Guan. 2 In the study focusing on Jiangsu Province, a multiple variable E-Mail: [email protected]. 3 logistic regression analysis showed that raising goats, raising E-Mail: [email protected]. 4 E-Mail: [email protected]. cattle, farming, and grazing were risk factors for SFTSV 5 E-Mail: [email protected]. http://dx.doi.org/10.1016/j.ijid.2017.01.003 1201-9712/© 2017 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). X. Xing et al. / International Journal of Infectious Diseases 55 (2017) 86–91 87 9,10 infection. Fan Ding et al. found that the odds ratio for SFTS was antigen cutoff value was 21.56PP (the mean +3 x SD PP values in 15 2.4 to 4.5 fold higher for patients who reported tick bites or the negative-control sera]]. presence of ticks in their living areas. Other independent risk factors included cat or cattle ownership and the reported presence Data Collection 11 of weeds and shrubs in the working environment. SFTSV RNA has been detected in ticks, animals, and SFTS cases, and the nucleic acid The professionals from provincial, city, and county CDCs were 1–4 sequences have high homology (93-100%) among them. These trained to interview and administer a standardized questionnaire findings suggest that ticks are the insect vectors for transmitting to cases and controls. Participants/patients were asked for their the virus to humans. However, several studies have provided demographic information (age, gender, ethnic group, home evidence to highlight the risk of person-to-person transmission of address, occupation), and they were asked questions concerning SFTSV through direct blood contact with the patient, especially their living environments (e.g., landform, environment, poultry, or 3,12,13 when the index patient has a high blood virus load. animal raising, house rats, wild animals), exposure history within Until now, the mode of SFTSV transmission has remained 2 weeks prior to fever onset (e.g., travel history, tick touch or bite, 9,10 unclear. The risk factors for SFTS infection are diverse, did not contact with suspected SFTS patients, contact with similar cases), clarify what kind of tick source exposure at high risk, and there is a and contact with animals and vectors (animal species and types of lack of targeted prevention and control measures for use in the vectors). Completed questionnaires were systematically verified regions of endemicity. Further investigations regarding the risk by provincial CDC study coordinators for data completeness. Data sources are needed to effectively prevent and control the disease. were double entered into an EpiData 3.02 (the EpiData Association, Here, we report the results of such a study conducted in Hubei Denmark, Europe) database, and this data entry was followed by Province, China. consistency checking. Materials and Methods Statistical Analysis Study design Pearson Chi-Squared and Fisher’s exact tests were used to compare the categorical variables, when appropriate. Maximum An individual matched case-control study design based on likelihood estimates for the matched odds ratios (ORs) and hospital data was applied to detect the potential risk sources for corresponding 95% confidence intervals (95%CIs) were calculated SFTS. Cases were defined as hospitalized patients with a fever using a conditional logistic regression model and the Wald test. (body temperature 38 C) associated with thrombocytopenia SPSS version 12.0 (IBM, Armonk, NY, USA) was used for all the 9 (platelet count < 100 Â 10 /L) and leukopenia (peripheral white statistical analyses. All the tests were 2-tailed, and the statistical 9 blood cell count < 3.0 Â 10 /L), and who tested positive in the significance level was set at P <0.05. laboratory for SFTSV infection (i.e., qRT-PCR or IgM ELISA during the acute illness phase). Controls were defined as matched patients Ethical approval with negative laboratory test results for SFTSV infection (i.e., qRT- PCR, IgM and IgG ELISA during the acute phase). The controls were The National Health and Family Planning Commission deter- randomly selected from a pool of patients who were first mined it was necessary to collect SFTS data as part of a continuing hospitalized in the same ward within 2 weeks of inclusion of public health investigation into an emerging outbreak. The study the cases, and they were matched by age (+/À 5 years) and gender was approved by the institutional review board of the Hubei according to a 1:2 matching condition. Provincial Center for Disease Control and Prevention. Written All Level 2 and above hospitals including the national, informed consent was obtained from all the participants after they provincial, municipal, county-level hospitals in Hubei Province were provided with detailed descriptions of the potential benefits carried out active surveillance of SFTS in the regions of endemicity of the study. in Hubei Province in 2011. When a patient with fever (body temperature 38 C) went to the hospital, the doctor conducted a Results routine blood test. A patient suspected to have a fever (body temperature 38 C) associated with thrombocytopenia and Characteristics of the study population leukopenia had to be admitted to hospital, and all those cases were reported to the Provincial Center for Disease Control and A total of 204 persons participated in this study, including Prevention (CDC) via the electronic National Notifiable Diseases 68 cases and 136 matched controls; therefore, the matching ratio Surveillance System.
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