Abstract
IntroductionTwo hantavirus species, Puumala (PUUV) and Dobrava-Belgrade (DOBV) virus (genotype Kurkino), are endemic in Germany. Recent PUUV outbreaks raised questions concerning increasing frequency of outbreaks and expansion of PUUV endemic areas.AimsTo describe the epidemiology of human PUUV and DOBV infections in Germany.MethodsWe conducted an observational retrospective study analysing national hantavirus surveillance data notified to the national public health institute and hantavirus nucleotide sequences from patients collected at the national consultation laboratory between 2001 and 2017. Matching molecular sequences with surveillance data, we conducted epidemiological, phylogenetic and phylogeographic analyses.ResultsIn total, 12,148 cases of symptomatic hantavirus infection were notified 2001–17 (mean annual incidence: 0.87/100,000; range: 0.09–3.51). PUUV infections showed a highly variable space-time disease incidence pattern, causing large outbreaks every 2–3 years with peaks in early summer and up to 3,000 annually reported cases. Sex-specific differences in disease presentation were observed. Of 202 PUUV nucleotide sequences obtained from cases, 189 (93.6%) fall into well-supported phylogenetic clusters corresponding to different endemic areas in Germany. DOBV infections caused few, mostly sporadic cases in autumn and winter in the north and east of Germany.ConclusionsThe frequency of PUUV outbreaks increased between 2001 and 2017 but our data does not support the suggested expansion of endemic areas. The epidemiology of PUUV and DOBV-Kurkino infections differs in several aspects. Moreover, the latter are relatively rare and combining efforts and data of several countries to identify risk factors and develop specific recommendations for prevention could be worthwhile.
Highlights
Two hantavirus species, Puumala (PUUV) and Dobrava-Belgrade (DOBV) virus, are endemic in Germany
The additional 31 cases notified as Sin Nombre and Hantaan infections without a corresponding travel history are regarded as erroneous data entries and likely represent additional Puumala virus (PUUV) or DOBV infections
We found pronounced space-time variability in disease incidence, clear but divergent seasonality of symptomatic PUUV and DOBV infections, distinct geographical clusters of PUUV strains and differences in disease presentation between women and men
Summary
Puumala (PUUV) and Dobrava-Belgrade (DOBV) virus (genotype Kurkino), are endemic in Germany. PUUV infections showed a highly variable space-time disease incidence pattern, causing large outbreaks every 2–3 years with peaks in early summer and up to 3,000 annually reported cases. New- or Old- World hantaviruses, the disease is characterised by different clinical pictures and described as Hantavirus (Cardio-)Pulmonary Syndrome (HPS/HCPS). Sometimes the term Nephropathia epidemica (NE) is used to describe the epidemic occurrence of renal disease without haemorrhagic symptoms that are linked to infections with strains occurring in the northern and central part of Europe, Puumala virus (PUUV). Syndromes are not always as clear cut as their names suggest and pulmonary and renal complications can occur in HFRS and HPS/HCPS, respectively [1,2,3]. Some hantavirus species can cause infection where the case fatality ratio can be up to 50% [1,6,7,8]
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