Human cases of Sindbis fever in South Africa, 2006-2010.

Sindbis virus (SINV), the prototype positive-sense RNA alphavirus, causes febrile arthritis and is present throughout Afro-Eurasia. Little is known of the epidemiology of Sindbis fever due to insufficient surveillance in most endemic countries. The epidemiological features of Sindbis fever in humans in South Africa are described here based on a retrospective study of suspected arbovirus cases submitted for laboratory investigation from 2006 to 2010. Cases were detected annually mostly during the late summer/early autumn months and an increase in cases was noted for 2010, coinciding with an outbreak of Rift Valley fever. Cases were reported most often from the central plateau of South Africa and involved mostly males. No severe or fatal cases were reported and cases were associated with febrile arthralgia as commonly reported for SINV infection. Further surveillance is required to reveal the true extent of the morbidity of Sindbis fever in South Africa.

Experimental detection of Rift Valley fever virus by reverse transcription-polymerase chain reaction assay in large samples of mosquitoes.

A reverse transcription-polymerase chain reaction (RT-PCR) was assessed in laboratory tests to detect the presence of single Aedes aegypti (L.) or Eretmapodites quinquevittatus Theobald mosquitoes infected with Rift Valley fever virus in pools of mosquitoes, 50-600 in size, from laboratory colonies or mixed field collections. The viral RNA was detected in all pools containing infected mosquitoes and was shown to be as sensitive as infant mice but more sensitive than Vero cell cultures for virus detection. Pools diluted down to the equivalent of 1:16 000 mosquitoes were also positive by RT-PCR. RNAs from 4 other phleboviruses were negative, there were no false positives and the procedure followed, with the 2 particular primers chosen, gave consistently clear bands of the PCR products on agarose gels without nested PCR being necessary.

Clinical virology of Ebola hemorrhagic fever (EHF): virus, virus antigen, and IgG and IgM antibody findings among EHF patients in Kikwit, Democratic Republic of the Congo, 1995.

Ebola hemorrhagic fever (EHF) patients treated at Kikwit General Hospital during the 1995 outbreak were tested for viral antigen, IgG and IgM antibody, and infectious virus. Viral antigen could be detected in virtually all patients during the acute phase of illness, while antibody was not always detectable before death. Virus was also isolated from patients during the course of their febrile illness, but attempts to quantify virus in Vero E6 cells by standard plaque assay were often unsuccessful. IgG and IgM antibody appeared at approximately the same time after disease onset (8-10 days), but IgM persisted for a much shorter period among the surviving convalescent patients. IgG antibody was detectable in surviving patients through about 2 years after onset, the latest time that samples were obtained. Detection of Ebola virus antigens or virus isolation appears to be the most reliable means of diagnosis for patients with suspected acute EHF, since patients with this often-fatal disease (80% mortality) may not develop detectable antibodies before death.

Experimental infection of ostriches with Crimean-Congo haemorrhagic fever virus.

Following the occurrence of an outbreak of Crimean-Congo haemorrhagic fever (CCHF) among workers at an ostrich abattoir in South Africa in 1996, 9 susceptible young ostriches were infected subcutaneously with the virus in order to study the nature of the infection which they undergo. The ostriches developed viraemia which was demonstrable on days 1-4 following infection, with a maximum intensity of 4.0 log10 mouse intracerebral LD50/ml being recorded on day 2 in 1 of the birds. Virus was detectable in visceral organs such as spleen, liver and kidney up to day 5 post-inoculation, 1 day after it could no longer be found in blood. No infective virus was detected in samples of muscle, but viral nucleic acid was detected by reverse transcription-polymerase chain reaction in muscle from a bird sacrificed on day 3 following infection. It was concluded that the occurrence of infection in ostriches at abattoirs could be prevented by keeping the birds free of ticks for 14 days before slaughter.

The use of a reverse transcription-polymerase chain reaction for the detection of viral nucleic acid in the diagnosis of Crimean-Congo haemorrhagic fever.

A reverse transcription-polymerase chain reaction (RT-PCR) was applied retrospectively to 80 stored serum samples from 45 confirmed Crimean-Congo haemorrhagic fever (CCHF) patients in southern Africa, and it was found that viral RNA could be detected in a proportion of samples up to day 16 of illness. Early in the disease there is relatively good correlation between the results obtained by RT-PCR and virus isolation, but after the first week it appears that infective virus is progressively cleared from serum while nucleic acid remains demonstrable in a proportion of patients well into convalescence. A further 47 serum samples from 38 patients with suspected viral haemorrhagic fever, 19 of whom proved to be cases of CCHF, were tested prospectively on being received at the laboratory. The combined use of RT-PCR with ethidium bromide stained gels for the detection of viral RNA, plus indirect immunofluorescence for the detection of IgG and IgM antibodies to CCHF virus, permitted a presumptive diagnosis to be reported within 8 h of receiving the first specimen from 18/19 cases of the disease studied prospectively. The nineteenth case was confirmed within 48 h when antibody response was demonstrated in a second serum sample. Viral nucleic acid was not detected in serum samples from 19 patients in whom alternative diagnoses were established.

Immunohistochemical and in situ localization of Crimean-Congo hemorrhagic fever (CCHF) virus in human tissues and implications for CCHF pathogenesis.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is a potentially fatal disease that occurs in parts of Africa, Asia, and eastern Europe, and that is caused by a recently emerged bunyavirus. Rapid laboratory diagnosis of CCHF infection is essential and is currently performed by virus isolation and serology. Histopathologic studies have been limited to a small number of cases, and little is known about the cellular tropism of CCHF virus and the pathogenesis of this disease. DESIGN: We conducted a retrospective case analysis of 12 patients with a diagnosis of CCHF infection, confirmed by virus isolation, who were evaluated at the Special Pathogens Unit, National Institute for Virology, South Africa. The clinicopathologic features of CCHF and the diagnostic role of virus isolation as compared with serology, immunohistochemistry, and in situ hybridization were evaluated. Additionally, the distribution of CCHF virus in human tissues was examined. RESULTS: The clinical and histopathologic features of CCHF resemble those of other viral hemorrhagic fevers. Of the 12 patients with virus isolation-confirmed CCHF infection, 5 were positive by serology, 10 by immunohistochemistry, and 5 by in situ hybridization. Immunohistochemistry and in situ hybridization analyses showed that the mononuclear phagocytes, endothelial cells, and hepatocytes are main targets of infection. Association of parenchymal necrosis in liver with viral infection suggests that cell damage may be mediated by a direct viral cytopathic effect. CONCLUSIONS: The diagnosis of CCHF, suspected by history and clinical features, can be supported histopathologically. However, since the pathologic features resemble those of other viral hemorrhagic fevers, an unequivocal diagnosis can be made only by laboratory tests. The utility of immunohistochemistry as a sensitive and rapid diagnostic modality was established by the high degree of concordance with virus isolation. Infection of mononuclear phagocytes, endothelial cells, and hepatocytes may play a critical role in the pathogenesis of CCHF.

Isolation and phylogenetic characterization of Ebola viruses causing different outbreaks in Gabon.

Three outbreaks of Ebola hemorrhagic fever have recently occurred in Gabon. Virus has been isolated from clinical materials from all three outbreaks, and nucleotide sequence analysis of the glycoprotein gene of the isolates and virus present in clinical samples has been carried out. These data indicate that each of the three outbreaks should be considered an independent emergence of a different Ebola virus of the Zaire subtype. As in earlier Ebola virus outbreaks, no genetic variability was detected between virus samples taken during an individual outbreak.

Experimental inoculation of plants and animals with Ebola virus.

Thirty-three varieties of 24 species of plants and 19 species of vertebrates and invertebrates were experimentally inoculated with Ebola Zaire virus. Fruit and insectivorous bats supported replication and circulation of high titers of virus without necessarily becoming ill; deaths occurred only among bats that had not adapted to the diet fed in the laboratory.

Investigation of tick-borne viruses as pathogens of humans in South Africa and evidence of Dugbe virus infection in a patient with prolonged thrombocytopenia.

In the course of investigating suspected cases of viral haemorrhagic fever in South Africa patients were encountered who had been bitten by ticks, but who lacked evidence of infection with Crimean-Congo haemorrhagic fever (CCHF) virus or non-viral tick-borne agents. Cattle sera were tested by enzyme-linked immunoassay to determine whether tick-borne viruses other than CCHF occur in the country. The prevalence of antibody in cattle sera was 905/2116 (42.8%) for CCHF virus, 70/1358 (5.2%) for Dugbe, 21/1358 (1.5%) for louping ill, 6/450 (1.3%) for West Nile, 7/1358 (0.5%) for Nairobi sheep disease, 3/625 (0.5%) for Kadam and 2/450 (0.4%) for Chenuda. No reactions were recorded with Hazara, Bahig, Bhanja, Thogoto and Dhori viruses. The CCHF findings confirmed previous observations that the virus is widely prevalent within the distribution range of ticks of the genus Hyalomma, while antibody activity to Dugbe antigen was detected only within the distribution range of the tick Amblyomma hebraeum. Cross-reactivity for the nairoviruses, Hazara, Nairobi sheep disease and Dugbe, was detected in serum samples from 3/72 human patients with confirmed CCHF infection, and serum from 1/162 other patients reacted monospecifically with Dugbe antigen. The latter patient suffered from febrile illness with prolonged thrombocytopenia.

Serodiagnosis of Crimean-Congo haemorrhagic fever.

Several methods for demonstrating antibody to Crimean-Congo haemorrhagic fever virus were compared on serum samples taken from 101 patients during the acute stage of illness and at intervals for up to 59 months thereafter, with emphasis on early detection of the immune response. The deaths of 23 patients on days 5-14 of illness were ascribed to the effects of the disease; two patients died later from other causes. Very few of the patients who died from the acute illness mounted an antibody response detectable by the methods tested. Four patients who died and 18 who recovered were treated with immune plasma collected from recovered patients. Treated patients acquired IgG antibody from the plasma, but it was possible to discern the onset of an endogenous IgM response in those individuals who survived the disease by all of the methods tested. Indirect immunofluorescence (IF) tests detected IgM and/or IgG antibodies at the earliest on day 4 of illness in about 10% of patients who survived the disease, and by day 9 all survivors had antibodies demonstrable by IF. A biotin-streptavidin IF technique offered no advantage over the standard IF test for the early detection of IgG antibody, but demonstrated higher antibody titres and detected IgM antibody earlier in about a quarter of the patients tested. An IgM-capture enzyme-linked immunoassay (ELISA) and an IgG sandwich ELISA demonstrated higher antibody titres than did IF tests, and detected antibody responses at an earlier stage of infection than did IF tests in about one-fifth of patients, but the reverse was true in a similar proportion of instances. A competition ELISA, which detected total antibody activity, produced lower titres than did the IgM and IgG ELISAs, but yielded results which were in close agreement with the findings in IF tests. It was concluded that the IF tests were most convenient for use in making a rapid serodiagnosis of the disease.

Viraemic transmission of Crimean-Congo haemorrhagic fever virus to ticks.

In order to determine the way in which vertebrates infected with Crimean-Congo haemorrhagic fever (CCHF) virus and potential ixodid tick vectors interact in nature, immature and adult ticks of several species were fed on viraemic mammals and then assayed for virus content at varying times after feeding. CCHF virus was not isolated from ticks of six species tested after feeding as adults and immature forms on sheep with viraemia of 10(2.5-3.2) LD 50/ml, nor from larval ticks fed on guinea-pigs and white-tailed rats with viraemia of 10(1.9-2.7) LD 50/ml. In contrast, virus was isolated from 10 of 152 pools of engorged adult ticks of 5 species that fed on cattle with viraemia of 10(1.5-2.7) LD 50/ml and from 3 of 137 female ticks after oviposition. Infection was transmitted to larval and nymphal Hyalomma truncatum and H. marginatum rufipes, but not to Rhipicephalus evertsi evertsi, from a scrub hare with viraemia of 10(4.2) LD 50/ml but only nymphal H. truncatum and H. m. rufipes became infected from scrub hares with viraemia of 10(2.6-2.7) LD 50/ml. Infection was transmitted trans-stadially in H. m. rufipes and H. truncatum infected as nymphae, and adult H. m. rufipes transmitted infection to a sheep. No evidence of transovarial transmission was found in larval progeny of ticks exposed to CCHF virus as adults on sheep and cattle or as immatures on scrub hares.

Antibody response in Crimean-Congo hemorrhagic fever.

IgG and IgM antibodies became demonstrable by indirect immunofluorescence on days 7 to 9 of illness in 35 survivors of Crimean-Congo hemorrhagic fever. Maximum titers of antibody were usually attained in the second to third week of illness. Titers of IgM declined gradually thereafter and were low or negative by the fourth month. In some patients titers of IgG increased markedly between 2 and 4 months after onset of illness and remained readily demonstrable by indirect immunofluorescence 3 years after infection. Endogenous antibody response was demonstrated in only two of 15 patients who died of infection. Techniques for demonstrating antibody were (in order of decreasing sensitivity) enzyme-linked immunosorbent assay, reversed passive hemagglutination-inhibition, indirect immunofluorescence, fluorescent-focus reduction, complement-fixation, and immunodiffusion. Most patients developed relatively low levels of neutralizing antibodies (range, 1:8 to 1:32 by fluorescent-focus reduction tests), but some developed titers of 1:256 to 1:512. Plasma intended for therapeutic use should be selected on the basis of its neutralizing ability.

Viremia and antibody response of small African and laboratory animals to Crimean-Congo hemorrhagic fever virus infection.

Eleven species of small African wild mammals, laboratory rabbits, guinea pigs, and Syrian hamsters were infected with Crimean-Congo hemorrhagic fever (CCHF) virus. Low-titered viremia followed by development of antibody was observed in scrub hares (Lepus saxatilis), Cape ground squirrels (Xerus inauris), red veld rats (Aethomys chrysophilus), white tailed rats (Mystromys albicaudatus), bushveld gerbils (Tatera leucogaster), striped mice (Rhabdomys pumilio), and guinea pigs. The maximum viremic titer in 4 scrub hares was 10(1.7-4.2) 50% mouse lethal doses/ml. Viremia was detected in 1/17 infected laboratory rabbits. Antibody response was only detected in South African hedgehogs (Atelerix frontalis), highveld gerbils (T. brantsii), Namaqua gerbils (Desmodillus auricularis), 2 species of multimammate mouse (Mastomys natalensis and M. coucha), and Syrian hamsters. The results of the study indicate that a proportion of infected scrub hares develop CCHF viremia of an intensity shown in the Soviet Union to be sufficient for infection of feeding immature ixodid ticks, but that South African hedgehogs and wild rodents are unlikely to be of importance as maintenance hosts of the virus in southern Africa.

The clinical pathology of Crimean-Congo hemorrhagic fever.

Observations were made of 15 fatal and 35 nonfatal Crimean-Congo hemorrhagic fever (CCHF) infections diagnosed from February 1981 to March 1987 in Kimberly and Sandringham, Republic of South Africa. Following an incubation period of 2-9 days after exposure to infection, patients had a sudden onset of disease with fever, nausea, severe headache, and myalgia. Petechial rash and hemorrhagic signs such as epistaxis, hematemesis, and melena supervened on days 3-6 of illness. Deaths occurred on days 5-14 of illness. Patients with fatal infections had thrombocytopenia and markedly elevated levels of serum aspartate and alanine aminotransaminases, gamma-glutamyltransferase, lactic dehydrogenase, creatine kinase, bilirubin, creatinine, and urea. Total protein, albumin, fibrinogen, and hemoglobin levels were depressed. Values for prothrombin ratio, activated partial thromboplastin time, thrombin time, and fibrin degradation products were grossly elevated, findings that indicate the occurrence of disseminated intravascular coagulopathy. Many of the clinical pathologic changes were evident at an early stage of the disease and had a highly predictive value for fatal outcome of infection. Changes were present but less marked in nonfatal infections.

Field and laboratory investigation of Crimean-Congo haemorrhagic fever virus (Nairovirus, family Bunyaviridae) infection in birds.

In November 1984 a case of Crimean-Congo haemorrhagic fever (CCHF) occurred in a worker who became ill after slaughtering ostriches (Struthio camelus) on a farm near Oudtshoorn in the Cape province of South Africa. The diagnosis was confirmed by isolation of CCHF virus from the patient's serum and by demonstration of a specific antibody response. It was suspected that infection was acquired either by contact with ostrich blood or by inadvertently crushing infected Hyalomma ticks while skinning ostriches. Reversed passive haemagglutination-inhibition antibody to CCHF virus was detected in the sera of 22/92 ostriches from farms in Oudtshoorn district, including 6/9 from the farm where the patient worked, but not in the sera of 460 birds of 37 other species. In pathogenicity studies domestic chickens proved refractory to CCHF infection, but viraemia of low intensity (maximum titre 2.5 log10 mouse ic LD50/ml) followed by a transient antibody response occurred in blue-helmeted guinea fowl (Numidia meleagris). These results offer the first direct evidence that some bird species are susceptible to CCHF virus infection.

Epidemiologic and clinical features of Crimean-Congo hemorrhagic fever in southern Africa.

Following the diagnosis in 1981 of the first case of Crimean-Congo hemorrhagic fever (CCHF) in South Africa, an antibody survey was undertaken on cattle sera to determine the distribution of the virus and specific diagnostic tests were routinely applied to specimens from suspected cases of hemorrhagic fever to establish the medical significance of its presence. Antibody to CCHF virus was demonstrated by reversed passive hemagglutination-inhibition technique in 2,460/8,667 (28%) cattle sera and in 140/180 herds tested in South Africa, as well as in 347/763 (45%) cattle sera and in 32/34 (94%) herds tested in Zimbabwe. The antibody was found in all major cattle farming areas, but was of low prevalence along the southern coast where 2 of the 3 species of Hyalomma tick which occur in South Africa are absent. From February 1981 to January 1986, inclusive, 29 indigenous cases of CCHF were diagnosed in 16 outbreaks which arose in various locations throughout South Africa. A further 2 imported cases of CCHF arose in Zaire and Tanzania. The clinical features of infection conformed to the classical descriptions of CCHF in the Soviet Union. The fatal outcome in 11/31 cases indicates that the African disease is no less severe than that which occurs in Eurasia. It is inferred that the virus is widespread in all countries in Africa and Eurasia which lie within the limits of world distribution of ticks of the genus Hyalomma.

Comparative tests for detection of plague antigen and antibody in experimentally infected wild rodents.

The enzyme-linked immunosorbent assay (ELISA) was compared with other standard tests for detection of plague (Yersinia pestis) antibody and antigen in multimammate mice (Mastomys coucha and M. natalensis) which were experimentally infected and then killed at daily intervals postinoculation. For detection of antibody in sera from M. natalensis, the immunoglobulin G (IgG) ELISA was equivalent in sensitivity to passive hemagglutination and more sensitive than the IgM ELISA and complement fixation. Antibody was first detected on postinfection day 6 by all four tests, but IgM ELISA titers had declined to undetectable levels after 8 weeks. For detection of fraction 1 Y. pestis antigen in rodent organs, the ELISA was less sensitive than fluorescent antibody but more sensitive than complement fixation or immunodiffusion. Plague fraction 1 antigen was detected in 16 of 34 bacteremic sera from M. coucha and M. natalensis. The threshold sensitivity of the ELISA was approximately 10(5) Y. pestis per ml.

Comparison of methods for isolation and titration of Crimean-Congo hemorrhagic fever virus.

The fluorescence focus assay and the plaque assay in CER cells were compared with mouse inoculation for the isolation and titration of Crimean-Congo hemorrhagic fever virus. The fluorescence focus assay and the plaque assay were of similar sensitivity, but both produced 10- to 100-fold lower titers than did mouse inoculation. For specimens from 26 Crimean-Congo hemorrhagic fever patients in South Africa, virus was isolated from 20 by mouse inoculation and from only 11 by cell culturing. Although cell cultures were less sensitive for the isolation of virus from clinical specimens, they produced diagnostic results much more rapidly.

Experimental plague infection in South African wild rodents.

Susceptibility studies were undertaken to determine the response of some South African wild rodent species to experimental plague (Yersinia pestis) infection. A degree of plague resistance was found in three gerbil species captured in the plague enzootic region of the northern Cape Province, these being the Namaqua gerbil, Desmodillus auricularis, (LD50 1 X 10(6) organisms), the bushveld gerbil, Tatera leucogaster, (LD50 9.1 X 10(5)) and the highveld gerbil, T. brantsii (LD50 4 X 10(2)). Animals from a population of the four-striped mouse, Rhabdomys pumilio, captured in the plague area of Port Elizabeth, proved moderately resistant to experimental plague infection (LD50 1.3 X 10(4)) while those from another population of the same species captured in a plague-free area of the Orange Free State were extremely susceptible (LD50, 5 organisms). The response of both populations however was a heterogeneous one. Marked differences in susceptibility were also found between two populations of multimammate mice, Mastomys natalensis (2n = 32) although both originated from areas outwith the known distribution of plague in southern Africa. The 50% infectious dose was relatively high in T. leucogaster (3.2 X 10(2)) and D. auricularis (1.7 X 10(3)), but was low (2-16 organisms) in the other rodent species tested. The plague antibody response, determined by enzyme-linked immunosorbent assay (ELISA), was extremely short-lived in T. leucogaster, only 10% of inoculated animals remaining seropositive at low titres after 11 weeks. Antibodies persisted for only slightly longer in the sera of T. brantsii which were reinoculated with 2 X 10(3) plague organisms 6 weeks after initial challenge. The demonstration of the existence of both susceptible and resistant populations of R. pumilio and M. natalensis indicates that these species must be considered as potential plague reservoir hosts in parts of South Africa. The results suggest that resistance to plague infection in previously epizootic hosts in the northern Cape Province such as Tatera sp. and D. auricularis has arisen through continual selective pressure of the organism. If the findings are applicable to gerbil populations in other plague enzootic regions of South Africa it is probable that acquired plague resistance has been responsible for the absence of gerbil epizootics and consequently for the dramatic decline in human plague outbreaks in South Africa since 1950.

A nosocomial outbreak of Crimean-Congo haemorrhagic fever at Tygerberg Hospital. Part V. Virological and serological observations.

A nosocomial outbreak of Crimean-Congo haemorrhagic fever occurred in Tygerberg Hospital near Cape Town in September 1984 when 7 medical personnel became ill after admission of an index patient. The disease was fatal in the index and 1 secondary case, and was confirmed in the index and 6 secondary cases by isolation of the virus. An antibody response was demonstrated in the remaining patient, thought to be a tertiary case, but the fact that the patient received immune plasma therapy raises doubts about the validity of the diagnosis. The index case had contact with ticks and horses but his infection could not be related to a specific incident.