Hantavirus Carried Home: A Sin Nombre Virus Case in Israel After a U.S. Trip, 2017

In November 2017 CDC confirmed Sin Nombre virus (SNV) infection in a previously healthy 47-year-old man hospitalized in Israel — the first confirmed case of SNV infection exported from the United States.

The case

From October 3 to 9, 2017, the man vacationed with his family in Arizona, Nevada and Utah. They hiked and biked the Grand Canyon's South Rim and Zion National Park and took a guided tour through Antelope Cave.

On November 7, about 3 weeks after returning to Israel, he was hospitalized with fever, cough and shortness of breath needing bilevel positive airway pressure. A chest x-ray showed diffuse reticulonodular infiltrates with consolidation at the right costophrenic angle and in the retrocardiac space. Given his travel and symptoms, doctors suspected hantavirus pulmonary syndrome, which kills approximately 36% of patients. A blood sample from November 9 tested positive for SNV by PCR, with IgM and IgG antibody titers both at least 1:6,400. He recovered with supportive care and left the hospital on November 19. No one in his family became ill.

About Sin Nombre virus

• SNV is a hantavirus spread to people mainly through contact with the urine or droppings of infected deer mice.
• Deer mice live across most of the continental United States, but transmission is most common in the Four Corners region — Arizona, Colorado, New Mexico and Utah.
• Illness usually begins 1–5 weeks after exposure.
• It does not spread from person to person, and clusters of cases are uncommon.

Looking for the source

The man recalled no contact with rodents, nests or droppings where he stayed or during his activities. Arizona and Utah health officials found no sign of rodent infestation at the inns and hotels where the family stayed. At Antelope Cave, though, they found rodent burrowing around the entrances and where the floor meets the walls — and tour guides are known to toss sand from the floor into the air so sunbeams show up in photographs, which could expose visitors to airborne rodent droppings. No definite source was found, but the infection most likely came from his outdoor activities.

Lessons

• Clinicians and public health workers should consider hantavirus pulmonary syndrome in travelers returning ill from the southwestern United States.
• Popular tourist sites should give visitors information on the risks and how to reduce them.
• Tour operators should be encouraged to leave the canyon floor undisturbed.

Sources

Based on Kofman A, Rahav G, Yazzie D, et al., "Notes from the Field: Exported Case of Sin Nombre Hantavirus Pulmonary Syndrome — Israel, 2017," MMWR Vol. 67, No. 40, CDC; a work of the United States government in the public domain. CDC has published an erratum for this report.