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Inside Out Prospective 26 TH Anniversary of Hantavirus – the 1993 Outbreak Response

Reflecting on the 26th Anniversary of the 1993 Hantavirus Outbreak and its impact on the Navajo community, highlighting challenges, unfair media portrayal, economic impact, and cultural responses. Join the conversation at the Hantavirus Conference 2019.

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Inside Out Prospective 26 TH Anniversary of Hantavirus – the 1993 Outbreak Response

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  1. Inside Out Prospective26TH Anniversary of Hantavirus – the 1993 Outbreak Response Herman Shorty, Director Navajo Environmental Health & Protection Program Navajo Department of Health For HANTAVIRUS CONFERENCE 2019 April 8 – 9, 2019 Diné College, Tsaile Campus, Tsaile, AZ

  2. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Impact was Tremendous: Loss of Family Members / Community Members Unexplained Loss (Why) Unfair & Insensitive Media Conveyance (Sensationalism) Economic Impact (Tourism) Changed Things: Protocols; Informational (Clinical, Health & Safety, Manufacturing, etc.) Cultural Affirmation

  3. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 The epicenter:

  4. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Unfair & Insensitive Media Conveyance (Sensationalism): The Results: By mid-September, there were 36 confirmed cases, 18 of them among Native Americans. There have been 21 deaths. In nearby Gallup and Albuquerque, newspapers and broadcast stations referred to the deadly virus as "the mystery illness" or "the Four Corners disease" (the Navajo Nation covers 25,000 square miles of Arizona, New Mexico and Utah and borders Colorado). But larger outlets, including the Chicago Tribune, Cleveland Plain Dealer, San Francisco Chronicle, Vancouver Sun, Orlando Sentinel and CBS News have referred to the illness at least once as "Navajo flu" or a "Navajo disease." A few, such as Reuters and USA Today, used such terms well after the virus had been identified.

  5. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Unfair & Insensitive Media Conveyance (Sensationalism): “The Mystery Illness” “The Four Corners Disease” “Navajo Flu” “Navajo Disease”

  6. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Unfair & Insensitive Media Conveyance (Sensationalism): The Results: It created a climate where Navajo were turned away from restaurants and Navajo Children were asked for health certificates when arriving at summer camps. Children on out of state school field trips were turned away at there destinations: Amusement Parks, Hotel, etc., cancelled through no fault of there own. Prejudice / Discrimination unfairly upon the innocent.

  7. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Unfair & Insensitive Media Conveyance (Sensationalism): The Results “*ATTENTION* If you have fever along with muscle aches and pains, please stay in your car and we examine you there.”

  8. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Response: Epidemiological Survey Questionnaire Format Adjustment Survey Team Protocol Adjustments Insertion of Tribal Liaisons Field Investigation Confirmation = Validity of Approach Training of Others

  9. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Background: In the spring of 1993, a previously unknown disease, hantavirus pulmonary syndrome (HPS), was identified among residence of the southwestern Untied States1-3. The association of hantavirus with rodents reservoirs warrant recommendations to minimize exposure to wild rodents and based on current understanding of the epidemiologic features of hantavirus infections. Nichol ST, Spiropoulou CF, Morzunov S, el al. Genetic identification of hantavirus associated with an outbreak of acute respiratory illness. Science 1993;262:914–7. Childs JE, Ksiazek TG, Spiropoulou CF, et al. Serologic and genetic identification of Peromyscus maniculatus as the primary rodent reservoir for the new hantavirus in the southwestern Untied States. J Infect Dis 1994;169: 1271–80. Duchin JS, Koster FT, Peters CJ, et al. Hantavirus pulmonary syndrome: a clinical description of 17 patients with a newly recognized disease. N Engl J Med 1994;330:949–55.

  10. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Background (cont.): The dominant western society would have you believe the outbreak in the spring of 1993 was a previously unknown disease. However, our Navajo leaders reported that similar outbreaks had occurred in 1918, 1933, and 1934. Navajo tribal stories have identified mice as sources of bad luck and illness since the 19th century4. The association of these past similar outbreaks related to rodents too have warranted recommendations to minimize exposure to wild rodents and based in experience and cultural belief of Hozho (Harmony). Harmony because we have our world and rodents and other creatures have their worlds. We would not have survived as a Native Indigoes cultural society all these millenniums without our own Traditional sanitation guidelines. Fimrite, Peter (2012-09-23). "Hantavirus outbreak puzzles experts". SFGate. Retrieved 2013-04-09.

  11. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 The Deer Mouse (Peromyscus maniculatus) is a deceptively cute animal, with big eyes and ears. Its head and body measure approximately 2-3 inches (5cm – 7.5cm) in length, and the tail adds another 2 – 3 inches. In color, the deer mouse ranges from grey to reddish brown, depending on age. The underbelly is always white and the tail has clearly defined white sides. The hantavirus strain present in deer mice is Sin Nombre (SNV). The deer mouse is found throughout North America, preferring woodlands, but also appearing in desert areas.

  12. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Deer Mouse Habitat in North America The deer mouse is found throughout North America, preferring woodlands, but also appearing in desert areas.

  13. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 The Brush Mouse (Peromyscus boylii) is also a deceptively cute animal, with big eyes and ears. The brush mouse is medium-sized, with small ears and a long tail. It has yellowish-brown fur on the body, with slate grey under parts. The tail has only sparse hair for most of its length, but with a distinct brush-like tuft of hair at the tip (although the common name is, perhaps, more likely to come from brushy environment in which it lives). It has a head-body length of 86 to 105 mm (3.4 to 4.1 in) with a tail 88 to 115 mm (3.5 to 4.5 in) long. It is very similar in appearance to a number of closely related species of mouse living in the same area, although it can be distinguished from them by such features as the length of its tail, the size of its ears, and the presence of the tuft on the end of the tail.

  14. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 The Peromyscus Truei (pinon mouse) fur varies in color from a pale yellowish brown to a brownish black color, and their feet are a lighter color, varying between dusky and white. For this reason they can incorrectly be grouped with other "white footed mouse" (P. leucopus) but there are a few distinguishing differences. P. truei tends to have a larger size of the ear which is as large or larger than the hind foot. Larger tail size and heavier hair distribution on tail tip is also observed. They have a larger skull, auditory bullae are more inflated and possess a less robust zygomatic arch.

  15. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Other Rodent Reservoirs of Virus Causing HPS New York virus, hosted by the white-footed mouse, Peromycusleucopus. Black Creek Canal virus, hosted by the cotton rat, Sigmodonhispidus. Bayou virus, hosted by the rice rat, Oryzomyspalustris.

  16. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Several Other Sigmodontine Rodent Species in the US are associated with additional hantavirus that have yet to be implicated in human diseases. Peromycusboylii (Brush Mouse). Reithrodontomysmegalois (Western Harvest Mouse). Bayou virus, hosted by the rice rat, Oryzomyspalustris.

  17. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Field Investigation: Trapping, Collection of tissue samples (“Slicing & Dicing”)

  18. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Field Investigation: Trapping, Collection of tissue samples (“Slicing & Dicing”)

  19. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Field Investigation: Trapping, Collection of tissue samples (“Slicing & Dicing”)

  20. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Field Investigation: Trapping, Collection of tissue samples (“Slicing & Dicing”)

  21. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Field Investigation: Trapping, Collection of tissue samples (“Slicing & Dicing”)

  22. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Field Investigation: Trapping, Collection of tissue samples (“Slicing & Dicing”)

  23. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Field Investigation: Trapping, Collection of tissue samples (“Slicing & Dicing”)

  24. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Field Investigation: Trapping, Collection of tissue samples (“Slicing & Dicing”)

  25. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Field Investigation: Trapping, Collection of tissue samples (“Slicing & Dicing”) Characteristics of landscape and vegetation near Fort Lewis trapping web "A," southwestern Colorado. Photo courtesy of C. Calisher. B. Schematic representation of a trapping web showing the relative locations of the 148 trap stations. Small circles indicate the location of one Sherman trap, larger circles, one Sherman plus one Tomahawk trap. Diameter of the web was 200 m. After Parameter et al. Source: Parmenter CA, Yates TL, Parmenter RR, Mills JN, Childs JE, Campbell ML, et al. Small mammal survival and trapability in mark-recapture monitoring programs for hantavirus. J Wildl Dis 1998;34: 1-12.

  26. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Unsung Heroes: There were plenty Clinicians and Health Care Professionals, CHR’s (Community Health Representatives) Health Education Programs Public Health Nursing Environmental Health Offices Others

  27. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Unsung Heroes: The real heroes Control homes (home sites/campsites); Two per case homes (home sites/campsites); One at or within a mile; & One at or within five miles Each subject to the same protocols of the case home site.

  28. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 NOTE: Each Control Home was subject to the same protocols of the Case Home site. Unsung Heroes: The real heroes

  29. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Changed Things: Protocols; Informational (Clinical, Health & Safety, Manufacturing, etc.) Greatly improved or opened avenues for communication & sharing of information in the medical & clinical community. Mobile Home Construction Industry (Reduced larger diameter drilled holes for plumbing & electrical or fillings to reduce rodent entry points).

  30. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Changed Things: Protocols; Informational (Clinical, Health & Safety, Manufacturing, etc.). Changes in operational procedures. Utility workers (Phone, Electrical, etc.). National Parks Services. Small Mammal Trapping Programs, e.g., Los Alamos Laboratory's trapping in canyons in close proximity , etc. New clean-up and monitoring messages.

  31. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Response Results: Confirming understanding cycle and need maintaining risk reduction and prevention:

  32. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Response Results: Identification of Hantavirus infection being epidemiologically associated with the following situations: Increase numbers of host rodents in human dwelling; Occupying or cleaning previously vacant cabins or other dwellings that are actively infested with rodents; Cleaning barns and other outbuildings; Disturbing excreta or rodent nests around the home or workplace; Residing in or visiting areas where substantial increases have occurred in numbers or host rodents or numbers of hantavirus-infected host rodents;

  33. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Response Results: Identification of Hantavirus infection being epidemiologically associated with the following situations: (cont.) Handling mice without gloves; Keeping captive wild rodents as pets or research subjects; Handling equipment or machinery that has been in storage; Disturbing excreta in rodent-infested areas while hiking or camping; Sleeping on the ground; and; Hand plowing or planting.

  34. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Response Results: Recommendations for disease control and prevention is risk reduction: • Precautions to Limit Household Exposure to Rodents; • Reduction of Rodent Shelter and Food Sources Inside and Outside the Home; • Precautions for inside the Home; • Precautions for outside the Home; • Preventing Rodents from Entering the Home by Rodent-Proofing; • Precautions for Workers Frequently Exposed to Rodents; • Precautions for other Occupational Groups Having Potential Contact with Rodents.

  35. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Response Results: Recommendations for disease control and prevention is risk reduction: (cont.) • Precautions for Campers and Hikers; • Precautions for Cleanup of Rodent-Contaminated Areas and Dead Rodents; • Cleanup of Rodent Urine and Droppings and Contaminated Surfaces; • Cleanup of Dead Rodents and Rodent Nests; • Disinfecting Solutions; and • Cleaning Sheds and Other Outbuildings; • Special Precautions for Homes of Persons with Confirmed Hantavirus Infections or Buildings with Heavy Rodent Infestations; • Recommendations for Cleaning Homes or Buildings with Heavy Rodent Infestations;

  36. Inside Out Prospective26TH Anniversary of Hantavirus – 1993 Outbreak ResponseHANTAVIRUS CONFERENCE 2019April 8, 2019 Thank you Herman Shorty, Director Navajo Environmental Health & Protection Program Navajo Department of Health P.O. Box 1390 Window Rock, Arizona 86515 (928) 871–6349 (Office) herman.shorty@nndoh.org

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