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Investigation of an Outbreak of Rickettsial Febrile Illness in Guatemala, 2007

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Investigation of an Outbreak of Rickettsial Febrile Illness in Guatemala, 2007 International Journal of Infectious Diseases 17 (2013) e304–e311 Contents lists available at SciVerse ScienceDirect International Journal of Infectious Diseases jou rnal homepage: www.elsevier.com/locate/ijid § Investigation of an outbreak of rickettsial febrile illness in Guatemala, 2007 a,1 b,c d e d e Marina E. Eremeeva , Elsa Berganza , Gloria Suarez , Lorena Gobern , Erica Dueger , Leticia Castillo , f,g a a a h,i, Lissette Reyes , Mary E. Wikswo , Kyle F. Abramowicz , Gregory A. Dasch , Kim A. Lindblade * a Rickettsial Zoonoses Branch, Division of Vector-Borne Diseases, National Center for Emerging Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA b A´rea de Salud, Jutiapa, Guatemala c Field Epidemiology Training Program, CDC Regional Office for Central America and Panama, Guatemala City, Guatemala d Centro Nacional de Epidemiologı´a, Ministerio de Salud Pu´blica y Asistencia Social, Guatemala City, Guatemala e Laboratorio Nacional de Salud de Guatemala, Ministerio de Salud Pu´blica y Asistencia Social, Guatemala City, Guatemala f ´ Area de Salud, Santa Rosa, Guatemala g Global Disease Detection Branch, Division of Global Disease Detection and Emergency Response, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA h International Emerging Infections Program, CDC Regional Office for Central America and Panama, Guatemala City, Guatemala i Malaria Branch, Center for Global Health, US Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS A06, Atlanta, GA 30333, USA A R T I C L E I N F O S U M M A R Y Article history: Objectives: We describe an outbreak of spotted fever group (SFG) rickettsiosis that occurred in 2007 in a Received 10 May 2012 farming community in southeastern Guatemala. We identified 17 cases of an acute febrile illness, among Received in revised form 20 July 2012 which 10, including two fatalities, were confirmed or probable cases of rickettsial disease (case–fatality Accepted 2 November 2012 proportion 12%). Corresponding Editor: Jane Zuckerman, Methods: PCR, a microimmunofluorescence assay (IFA), and Western blotting were performed on London, UK patient samples, and PCR was performed on ticks. Results: Using an indirect IFA, seven of 16 (44%) ill persons tested had both IgM and IgG antibodies Keywords: reacting with one or more Rickettsia spp antigens; the other nine (56%) had only IgM titers or were Amblyomma cajennense seronegative. Antibodies to SFG protein and lipopolysaccharide were detected by Western blotting with Spotted fever rickettsiosis antigens of Rickettsia typhi, Rickettsia rickettsii, and Rickettsia akari. Only one sample, from an ill person Spotted fever group rickettsiae who died, tested positive by PCR for a SFG Rickettsia. PCR analysis of Amblyomma cajennense ticks from Guatemala domestic animals in the area detected the presence of SFG Rickettsia DNA in one of 12 ticks collected. Conclusions: Further studies in Guatemala are warranted to establish the prevalence of rickettsioses and to fully characterize the identity of the etiologic agents and vectors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. (RMSF), Rickettsia akari, the cause of rickettsialpox, and Rickettsia 1. Introduction 1–5 felis, the agent of flea-borne spotted fever. Recently, another species of SFG, Rickettsia parkeri, has been found to cause an In the Americas, several rickettsiae of the spotted fever group 6–8 eschar-associated rickettsiosis in the USA and in South America. (SFG) are endemic and pathogenic. The best known of these are The application of more versatile and accurate molecular tools for Rickettsia rickettsii, the cause of Rocky Mountain spotted fever the identification of rickettsiae from human specimens and ectoparasite samples has permitted the identification of new rickettsial agents and new tick vectors implicated in the § th The data reported in this manuscript were presented in part at the 57 Annual transmission of various rickettsiae, thus expanding our knowledge Meeting of the American Society for Tropical Medicine and Hygiene, New Orleans, of both the types of disease caused by rickettsiae and the December 7–11, 2008. * Corresponding author. Tel.: +1 404 718 4750; fax: +1 404 718 4815. geographic range of rickettsioses. E-mail address: [email protected] (K.A. Lindblade). Although R. rickettsii causing RMSF has been found in Mexico, 1 Jiann-Ping Hsu College of Public Health, Georgia Southern University, 501 Costa Rica, and Panama, where the disease is known as ‘fiebre Forest Dr., Statesboro, GA 30458, USA. 1201-9712/$36.00 – see front matter. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. http://dx.doi.org/10.1016/j.ijid.2012.11.011 M.E. Eremeeva et al. / International Journal of Infectious Diseases 17 (2013) e304–e311 e305 9–12 manchada’, the presence and characteristics of rickettsiae in evidence that 10 of the 17 patients apparently suffered from a Guatemala have not been well studied.In 1898, an outbreak of rickettsial disease. epidemic louse-borne typhus was reported from Quetzaltenango, which continued to experience small outbreaks of this disease 2. Materials and methods 13 between 1943 and 1956. Vaccination, sanitation, and louse- control measures apparently eliminated epidemic typhus by 2.1. Epidemiological investigation 13,14 1959. Subsequent surveillance identified epidemic typhus in several municipalities of Quetzaltenango between 1970 and Moyuta is a peri-urban community approximately 80 km from 13 1972; however, some of these later cases may have represented the capital, Guatemala City, in the department of Jutiapa on the recrudescent Brill–Zinsser disease. To date, neither SFG rickettsiae border with El Salvador, situated at 1283 m above sea level nor clinical cases resembling RMSF have been reported from (Figure 1). The maximum daily temperature averages 34 8C and Guatemala. minimum temperature 21 8C, with minimal seasonal variations. We describe an outbreak of febrile illness in the peri-urban Total annual rainfall averages 1400 mm per year, with one rainy farming community of Moyuta in the Department of Jutiapa, season between May and October. The small town of 17 499 Guatemala. The outbreak occurred from March to May 2007 and inhabitants is surrounded by pastures and farmland and is served resulted in illness in 17 persons, with two deaths. Here, we present by one health center. On May 16, 2007, the Health Area of Jutiapa was informed of the second of two deaths in the previous month Figure 1. Guatemala and neighboring countries. The location of Moyuta is shown on the map. e306 M.E. Eremeeva et al. / International Journal of Infectious Diseases 17 (2013) e304–e311 from a febrile illness of unknown origin among employees of a For WB, rickettsial cells purified from host cell debris were dairy farm. The Guatemala National Health Laboratory performed solubilized at room temperature and separated through 10% preliminary testing, and the presence of significantly high levels of sodium dodecyl sulfate (SDS) polyacrylamide gels, as described 15 IgG and IgM antibodies reacting to Rickettsia typhi and R. rickettsii previously, and were transferred to 45 mm nitrocellulose antigens was detected using an indirect microimmunofluores- membranes (Schleicher and Schuell Bioscience Inc., Keene, NH). cence assay (IFA) in the blood of four ill persons, including the first Non-specific protein binding sites were blocked with 5% non-fat fatality (Castillo, unpublished data). To identify the etiologic agent dry milk, followed by incubation with serum diluted at 1:100 and and prevent further cases, the Guatemalan Ministry of Public then with horseradish peroxidase (HRP)-labeled goat anti-human Health and Social Welfare (Ministerio de Salud Pu´ blica y Asistencia IgG (gamma-chain specific) and IgM Fc5 m antibody (Chemicon- Social, MSPAS), along with the Health Area of Jutiapa and the Millipore) at 1:2500 dilution. Bound enzyme was detected by Centers for Disease Control and Prevention (CDC) Regional Office reaction with substrate solution containing 0.015% 4-chloro-1- for Central America and Panama, initiated an investigation to naphthol (Bio-Rad, Hercules, CA), 0.015% hydrogen peroxide, and identify additional cases. This effort involved identifying additional 16.7% methanol in 0.02 M Tris-buffered solution (pH 7.5). The suspect cases, collecting appropriate biological samples from ill developed membranes were washed in water, dried between filter persons and domestic and wild animals, collecting ectoparasites, papers, and digitized. All serological tests were repeated twice and and conducting laboratory diagnostics. identical results were obtained on different dates by two different For the purposes of this outbreak investigation, a case was technicians. defined as fever and headache in a resident of the neighborhood surrounding the dairy farm (population 763) between March 1 and 2.5. PCR analysis of human specimens May 16, 2007. Household interviews were conducted in all 197 houses in the neighborhood using a questionnaire addressing type DNA was extracted from 200 ml of EDTA-whole blood using a and duration of symptoms, demographic characteristics of the ill QIAamp DNA Mini Kit (Qiagen, Valencia, CA). When blood persons and their occupations, and their domestic, peri-domestic, specimens were not available, serum or plasma was centrifuged or occupational exposure to pets, domestic animals, rodents, and for 10 min at 14 000 Â g and
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