User login
In May 2016, Tarrah Oliver had been working as a bench tech in hematology at Tséhootsooí Medical Center (TMC) for 4 years when the hospital launched a 5-point screen for detecting hantavirus cardiopulmonary syndrome (HCPS), a potentially fatal disease that disproportionately affects Native Americans.
Developed at the University of New Mexico, the 5-point screen was particularly useful for facilities like TMC, a 56-bed hospital in Arizona serving Navajo Nation patients. Although the Navajo make up only 1.7% of the population, they account for 18% of all reported HCPS cases in the US.
But Oliver, who was the laboratory Safety and Training supervisor, her department supervisor, and his assistant were the only people who knew how to do the screen. “I was storing completed worksheets in a folder,” Oliver said, “and soon I had to transfer them to a 3-inch binder because we had so many being ordered. I started saving slides that scored high so that I could show my fellow lab mates what certain characteristics looked like under the microscope.” She also created case studies to train staff using analyzer printouts and slides from the patients. “It was my little side project to take care of while I was working and training new employees in the hematology department.”
The screen was to become much more than a side project very quickly.
In 2017, there was a hantavirus outbreak in one of the nearby communities. A team from the Centers for Disease Control and Prevention (CDC) came out to visit the local hospitals to educate the medical staff on what to look for in their patients with suspected hantavirus. Among those: the TMC staff. The visit would prove both serendipitous and synergistic.
Mary Choi, MD, MPH, medical officer with the CDC Viral Special Pathogens Branch, said, “Members of my branch were asked to come to Navajo Nation [Lukachukai chapter, Arizona] because of a cluster of hantaviruses cases that had been occurring in the area over the course of a few years. During a meeting with medical providers at TMC, our team met Tarrah and she told us that TMC had implemented the screen. We were really intrigued and impressed by the initiative of this small community hospital.”
“We were excited that the CDC even knew we existed!” Oliver recalled. “This little lab in the middle of the reservation.”
HCPS is rare but severe. It can quickly progress from nonspecific initial symptoms, such as fever, body aches, and shortness of breath, to severe respiratory distress. Without immediate intervention, patients usually die within 24 to 48 hours of the onset of cardiopulmonary symptoms. “What makes the disease even more challenging,” said Choi, “is that some of the critical lifesaving measures that physicians normally employ to save a critically-ill patient can actually make the situation worse.
“For example, when HCPS patients reach the cardiopulmonary phase of the illness, their blood pressure will drop. The normal response to this is to give IV fluids (IVF). But in hantavirus, giving IVF can actually make the signs and symptoms of the disease worse and only judicious use of IVF is recommended.”
She gave other examples of treatment challenges: “Physicians are taught to intubate critically ill patients. However, intubation of hanta patients during the cardiopulmonary phase can actually be detrimental. Also, in general, extracorporeal membrane oxygenation (ECMO) is an intervention of last resort for most critically-ill patients. As the procedure essentially involves hooking the patient up to a heart-lung machine, which has a lot of complications, doctors do not do this unless they have to. But in hantavirus disease, early initiation of ECMO has been shown to significantly improve survival.”
“Another tricky thing about ECMO is that not all hospitals have an ECMO machine… oftentimes patients have to be transferred from one hospital to another because they need ECMO and it is not available where they are.” The ECMO-equipped facility closest to TMC is 170 miles away, at the University of New Mexico Hospital in Albuquerque.
For all those reasons, Dr. Choi said, it is critically important for physicians to know if the patient they are treating has hantavirus or not. The problem is, there is no rapid test for hantavirus disease. The tests have to be sent out to a laboratory and it can take days before physicians receive a test result. “This is where the 5-point screen is such a valuable tool. Although it is not a diagnostic test, it is a very accurate screening tool. Even better, it is readily and widely available, because to perform the screen, you only need a complete blood count (CBC) and a peripheral blood smear…which can be performed in the vast majority of laboratories and clinics. In addition, the CBC and peripheral blood smear are very commonly ordered tests.”
The screen could be particularly crucial for small community hospitals and clinics. “[TMC] took a screen developed by hematopathologists for hematopathologists,” Choi said, “and adapted it so that it could be performed by clinical laboratorians—because hematopathologists don’t exactly grow on trees! Once we heard about the work that TMC was doing, we knew that this was something we wanted to support and advocate for.”
“We started to throw around the idea of teaching this method to other laboratories on the reservation,” Oliver said. She and Mary Choi teamed up to “knock on everyone’s door to see who was utilizing the screening or if they had their own methods of detecting hantavirus in their patients.”
Two years later, they began holding training sessions at a nearby community college; they also trained an entire laboratory at their hospital in late 2019. Plans were to set up other training sessions towards the border towns before spring of 2020.
Then SARS-CoV-2 showed up.
Hantavirus or coronavirus?
COVID-19 hit the Navajo Nation like a sledgehammer. Native Americans in rural areas, as many Navajo are, may have multigenerational and extended families living in tight quarters, with limited access to running water, miles from the nearest healthcare facility. They were particularly vulnerable to a virus that thrives on close contact, at a time when the most common preventives were distancing, frequent handwashing, and testing. By May 2020, the Navajo Nation had surpassed the epicenters—New York and New Jersey—in cases of infection. Even as late as November 2021, the Navah Nation has reported > 37,000 positive cases, and nearly 1,500 confirmed deaths, despite reaching a 70% vaccination rate.
Making things ever more challenging: How do you know whether the patient has hantavirus or COVID-19? The distinction is critical because the disease courses of the 2 infections differ greatly. “The importance of [TMC’s] work was really brought home by the COVID pandemic,” Mary Choi said. “The signs and symptoms of early COVID and hantavirus are really indistinguishable. But the problem is that most people with COVID will live, while most people with hantavirus will die without critical care.”
The overall US case fatality rates are drastically different: 36% to 38% for hantavirus, 1.6% for COVID-19. In Arizona alone, of 81 patients who developed hantavirus (as of 2019), 27 died. In New Mexico, of 117 patients, 51 died.
“The scary part,” said Tarrah Oliver, “was that when patients were flooding our ER with symptoms exactly like those of hantavirus, I kept thinking that it was now up to us in the lab to scrutinize CBC results for any characteristics of hantavirus because our locum providers and permanent providers would likely not have hanta on their minds right now to suspect it.”
“Once COVID hit Navajo Nation, we really worried about how clinicians were going to distinguish between the two disease entities and worried about possible excess deaths of hanta because they were mistaken for COVID-19,” Choi says. “Unfortunately, in the spring of 2020, 2 fatal cases of hantavirus were reported. Their deaths were initially thought to be due to COVID, but later testing showed that they both died of hantavirus. We knew that we had to study whether the 5-point screen could distinguish between hantavirus disease and COVID.”
They conducted the comparison study at TMC and Emory, in Atlanta. TMC, as a small hospital, might not get many COVID cases while Emory, a large hospital system, had many COVID cases but rarely hantavirus cases (Box).
The researchers found that the screen did indeed work as they had hoped. No matter who performed the screen, the demographics of the population screened, or when in the COVID-19 disease course the sample was taken, individuals positive for COVID-19 received a low score on the screen. None of the participants who were positive for COVID-19 demonstrated all 5 hallmarks of hantavirus infection, and only 3 patients received a score of 4.
The screen was most accurate when the specimen was collected during the cardiopulmonary phase. Before the cardiopulmonary phase [BOX], there is a short febrile prodromal phase in which the platelets are starting to drop but aren’t low enough to be considered thrombocytopenic. Hematocrit and hemoglobin levels are still normal, and immunoblasts or plasma cells haven’t been released into the blood yet. “A patient’s score is likely to be pretty low or intermediate,” Tarrah Oliver said. “In the febrile prodromal phase, the patient will have chills, fever, headache and myalgia lasting 3 to 6 days, which might be written off as the flu or even COVID-19, especially if a provider is not familiar with the endemic regions of the Navajo Nation.”
“When we found that the screen could distinguish between the 2 diseases,” Choi said, “we worked frantically to write up the findings and publish so that healthcare providers would be aware of the value of this tool.”
“I couldn’t be more excited that the word is getting out in the medical community,” Oliver said. They plan to share the information as widely as possible, booking local radio spots, for instance. “We’re trying to disseminate our research across our partners on the reservation.”
The results of the research were recently published in the American Journal of Clinical Pathology. “Our next follow-up research will be an inter-rater reliability between TMC’s 2-year and 4-year-degree medical laboratorians and Emory’s pathologists performing the 5-point hantavirus screen on the same slides. We want to show that rural hospitals without the expertise of pathologists can perform this screen for their patients in a timely manner and still get the same outcomes.”
Lastly, and the most exciting, Oliver said, is putting that training manual she created to wider use. In addition to all the case studies she collected, analyzer printouts, and PowerPoint slides about the epidemiology, the manual includes a procedure, billing codes, and layout of what it looks like on certain medical record software that most Indian Health Service hospitals use. “With the manual, we may be able to expand our reach, so I won’t need to travel,” Oliver said. “We could use Zoom to reach further and I could explain it all while they have the manual right in front them.”
So far, nearly 200 screens have been performed at TMC. Four cases of hantavirus disease have been identified. The screen has proved successful, but for Oliver, there’s a personal reward. “I heard stories as a kid of relatives and friends succumbing to this mystery flu in the 1990s and how our parents protected us from it,” she said. “Now I feel like it’s my turn to take care of my family and friends from both hantavirus and COVID, our current ‘mystery flu.’ … I’ve realized that now I’m doing this for our people, the Diné (Navajo) people.”
This article offers some background and follow-up to Hantavirus Disease and COVID-19: Evaluation of the Hantavirus 5-Point Screen in 139 COVID-19 Patients
In May 2016, Tarrah Oliver had been working as a bench tech in hematology at Tséhootsooí Medical Center (TMC) for 4 years when the hospital launched a 5-point screen for detecting hantavirus cardiopulmonary syndrome (HCPS), a potentially fatal disease that disproportionately affects Native Americans.
Developed at the University of New Mexico, the 5-point screen was particularly useful for facilities like TMC, a 56-bed hospital in Arizona serving Navajo Nation patients. Although the Navajo make up only 1.7% of the population, they account for 18% of all reported HCPS cases in the US.
But Oliver, who was the laboratory Safety and Training supervisor, her department supervisor, and his assistant were the only people who knew how to do the screen. “I was storing completed worksheets in a folder,” Oliver said, “and soon I had to transfer them to a 3-inch binder because we had so many being ordered. I started saving slides that scored high so that I could show my fellow lab mates what certain characteristics looked like under the microscope.” She also created case studies to train staff using analyzer printouts and slides from the patients. “It was my little side project to take care of while I was working and training new employees in the hematology department.”
The screen was to become much more than a side project very quickly.
In 2017, there was a hantavirus outbreak in one of the nearby communities. A team from the Centers for Disease Control and Prevention (CDC) came out to visit the local hospitals to educate the medical staff on what to look for in their patients with suspected hantavirus. Among those: the TMC staff. The visit would prove both serendipitous and synergistic.
Mary Choi, MD, MPH, medical officer with the CDC Viral Special Pathogens Branch, said, “Members of my branch were asked to come to Navajo Nation [Lukachukai chapter, Arizona] because of a cluster of hantaviruses cases that had been occurring in the area over the course of a few years. During a meeting with medical providers at TMC, our team met Tarrah and she told us that TMC had implemented the screen. We were really intrigued and impressed by the initiative of this small community hospital.”
“We were excited that the CDC even knew we existed!” Oliver recalled. “This little lab in the middle of the reservation.”
HCPS is rare but severe. It can quickly progress from nonspecific initial symptoms, such as fever, body aches, and shortness of breath, to severe respiratory distress. Without immediate intervention, patients usually die within 24 to 48 hours of the onset of cardiopulmonary symptoms. “What makes the disease even more challenging,” said Choi, “is that some of the critical lifesaving measures that physicians normally employ to save a critically-ill patient can actually make the situation worse.
“For example, when HCPS patients reach the cardiopulmonary phase of the illness, their blood pressure will drop. The normal response to this is to give IV fluids (IVF). But in hantavirus, giving IVF can actually make the signs and symptoms of the disease worse and only judicious use of IVF is recommended.”
She gave other examples of treatment challenges: “Physicians are taught to intubate critically ill patients. However, intubation of hanta patients during the cardiopulmonary phase can actually be detrimental. Also, in general, extracorporeal membrane oxygenation (ECMO) is an intervention of last resort for most critically-ill patients. As the procedure essentially involves hooking the patient up to a heart-lung machine, which has a lot of complications, doctors do not do this unless they have to. But in hantavirus disease, early initiation of ECMO has been shown to significantly improve survival.”
“Another tricky thing about ECMO is that not all hospitals have an ECMO machine… oftentimes patients have to be transferred from one hospital to another because they need ECMO and it is not available where they are.” The ECMO-equipped facility closest to TMC is 170 miles away, at the University of New Mexico Hospital in Albuquerque.
For all those reasons, Dr. Choi said, it is critically important for physicians to know if the patient they are treating has hantavirus or not. The problem is, there is no rapid test for hantavirus disease. The tests have to be sent out to a laboratory and it can take days before physicians receive a test result. “This is where the 5-point screen is such a valuable tool. Although it is not a diagnostic test, it is a very accurate screening tool. Even better, it is readily and widely available, because to perform the screen, you only need a complete blood count (CBC) and a peripheral blood smear…which can be performed in the vast majority of laboratories and clinics. In addition, the CBC and peripheral blood smear are very commonly ordered tests.”
The screen could be particularly crucial for small community hospitals and clinics. “[TMC] took a screen developed by hematopathologists for hematopathologists,” Choi said, “and adapted it so that it could be performed by clinical laboratorians—because hematopathologists don’t exactly grow on trees! Once we heard about the work that TMC was doing, we knew that this was something we wanted to support and advocate for.”
“We started to throw around the idea of teaching this method to other laboratories on the reservation,” Oliver said. She and Mary Choi teamed up to “knock on everyone’s door to see who was utilizing the screening or if they had their own methods of detecting hantavirus in their patients.”
Two years later, they began holding training sessions at a nearby community college; they also trained an entire laboratory at their hospital in late 2019. Plans were to set up other training sessions towards the border towns before spring of 2020.
Then SARS-CoV-2 showed up.
Hantavirus or coronavirus?
COVID-19 hit the Navajo Nation like a sledgehammer. Native Americans in rural areas, as many Navajo are, may have multigenerational and extended families living in tight quarters, with limited access to running water, miles from the nearest healthcare facility. They were particularly vulnerable to a virus that thrives on close contact, at a time when the most common preventives were distancing, frequent handwashing, and testing. By May 2020, the Navajo Nation had surpassed the epicenters—New York and New Jersey—in cases of infection. Even as late as November 2021, the Navah Nation has reported > 37,000 positive cases, and nearly 1,500 confirmed deaths, despite reaching a 70% vaccination rate.
Making things ever more challenging: How do you know whether the patient has hantavirus or COVID-19? The distinction is critical because the disease courses of the 2 infections differ greatly. “The importance of [TMC’s] work was really brought home by the COVID pandemic,” Mary Choi said. “The signs and symptoms of early COVID and hantavirus are really indistinguishable. But the problem is that most people with COVID will live, while most people with hantavirus will die without critical care.”
The overall US case fatality rates are drastically different: 36% to 38% for hantavirus, 1.6% for COVID-19. In Arizona alone, of 81 patients who developed hantavirus (as of 2019), 27 died. In New Mexico, of 117 patients, 51 died.
“The scary part,” said Tarrah Oliver, “was that when patients were flooding our ER with symptoms exactly like those of hantavirus, I kept thinking that it was now up to us in the lab to scrutinize CBC results for any characteristics of hantavirus because our locum providers and permanent providers would likely not have hanta on their minds right now to suspect it.”
“Once COVID hit Navajo Nation, we really worried about how clinicians were going to distinguish between the two disease entities and worried about possible excess deaths of hanta because they were mistaken for COVID-19,” Choi says. “Unfortunately, in the spring of 2020, 2 fatal cases of hantavirus were reported. Their deaths were initially thought to be due to COVID, but later testing showed that they both died of hantavirus. We knew that we had to study whether the 5-point screen could distinguish between hantavirus disease and COVID.”
They conducted the comparison study at TMC and Emory, in Atlanta. TMC, as a small hospital, might not get many COVID cases while Emory, a large hospital system, had many COVID cases but rarely hantavirus cases (Box).
The researchers found that the screen did indeed work as they had hoped. No matter who performed the screen, the demographics of the population screened, or when in the COVID-19 disease course the sample was taken, individuals positive for COVID-19 received a low score on the screen. None of the participants who were positive for COVID-19 demonstrated all 5 hallmarks of hantavirus infection, and only 3 patients received a score of 4.
The screen was most accurate when the specimen was collected during the cardiopulmonary phase. Before the cardiopulmonary phase [BOX], there is a short febrile prodromal phase in which the platelets are starting to drop but aren’t low enough to be considered thrombocytopenic. Hematocrit and hemoglobin levels are still normal, and immunoblasts or plasma cells haven’t been released into the blood yet. “A patient’s score is likely to be pretty low or intermediate,” Tarrah Oliver said. “In the febrile prodromal phase, the patient will have chills, fever, headache and myalgia lasting 3 to 6 days, which might be written off as the flu or even COVID-19, especially if a provider is not familiar with the endemic regions of the Navajo Nation.”
“When we found that the screen could distinguish between the 2 diseases,” Choi said, “we worked frantically to write up the findings and publish so that healthcare providers would be aware of the value of this tool.”
“I couldn’t be more excited that the word is getting out in the medical community,” Oliver said. They plan to share the information as widely as possible, booking local radio spots, for instance. “We’re trying to disseminate our research across our partners on the reservation.”
The results of the research were recently published in the American Journal of Clinical Pathology. “Our next follow-up research will be an inter-rater reliability between TMC’s 2-year and 4-year-degree medical laboratorians and Emory’s pathologists performing the 5-point hantavirus screen on the same slides. We want to show that rural hospitals without the expertise of pathologists can perform this screen for their patients in a timely manner and still get the same outcomes.”
Lastly, and the most exciting, Oliver said, is putting that training manual she created to wider use. In addition to all the case studies she collected, analyzer printouts, and PowerPoint slides about the epidemiology, the manual includes a procedure, billing codes, and layout of what it looks like on certain medical record software that most Indian Health Service hospitals use. “With the manual, we may be able to expand our reach, so I won’t need to travel,” Oliver said. “We could use Zoom to reach further and I could explain it all while they have the manual right in front them.”
So far, nearly 200 screens have been performed at TMC. Four cases of hantavirus disease have been identified. The screen has proved successful, but for Oliver, there’s a personal reward. “I heard stories as a kid of relatives and friends succumbing to this mystery flu in the 1990s and how our parents protected us from it,” she said. “Now I feel like it’s my turn to take care of my family and friends from both hantavirus and COVID, our current ‘mystery flu.’ … I’ve realized that now I’m doing this for our people, the Diné (Navajo) people.”
This article offers some background and follow-up to Hantavirus Disease and COVID-19: Evaluation of the Hantavirus 5-Point Screen in 139 COVID-19 Patients
In May 2016, Tarrah Oliver had been working as a bench tech in hematology at Tséhootsooí Medical Center (TMC) for 4 years when the hospital launched a 5-point screen for detecting hantavirus cardiopulmonary syndrome (HCPS), a potentially fatal disease that disproportionately affects Native Americans.
Developed at the University of New Mexico, the 5-point screen was particularly useful for facilities like TMC, a 56-bed hospital in Arizona serving Navajo Nation patients. Although the Navajo make up only 1.7% of the population, they account for 18% of all reported HCPS cases in the US.
But Oliver, who was the laboratory Safety and Training supervisor, her department supervisor, and his assistant were the only people who knew how to do the screen. “I was storing completed worksheets in a folder,” Oliver said, “and soon I had to transfer them to a 3-inch binder because we had so many being ordered. I started saving slides that scored high so that I could show my fellow lab mates what certain characteristics looked like under the microscope.” She also created case studies to train staff using analyzer printouts and slides from the patients. “It was my little side project to take care of while I was working and training new employees in the hematology department.”
The screen was to become much more than a side project very quickly.
In 2017, there was a hantavirus outbreak in one of the nearby communities. A team from the Centers for Disease Control and Prevention (CDC) came out to visit the local hospitals to educate the medical staff on what to look for in their patients with suspected hantavirus. Among those: the TMC staff. The visit would prove both serendipitous and synergistic.
Mary Choi, MD, MPH, medical officer with the CDC Viral Special Pathogens Branch, said, “Members of my branch were asked to come to Navajo Nation [Lukachukai chapter, Arizona] because of a cluster of hantaviruses cases that had been occurring in the area over the course of a few years. During a meeting with medical providers at TMC, our team met Tarrah and she told us that TMC had implemented the screen. We were really intrigued and impressed by the initiative of this small community hospital.”
“We were excited that the CDC even knew we existed!” Oliver recalled. “This little lab in the middle of the reservation.”
HCPS is rare but severe. It can quickly progress from nonspecific initial symptoms, such as fever, body aches, and shortness of breath, to severe respiratory distress. Without immediate intervention, patients usually die within 24 to 48 hours of the onset of cardiopulmonary symptoms. “What makes the disease even more challenging,” said Choi, “is that some of the critical lifesaving measures that physicians normally employ to save a critically-ill patient can actually make the situation worse.
“For example, when HCPS patients reach the cardiopulmonary phase of the illness, their blood pressure will drop. The normal response to this is to give IV fluids (IVF). But in hantavirus, giving IVF can actually make the signs and symptoms of the disease worse and only judicious use of IVF is recommended.”
She gave other examples of treatment challenges: “Physicians are taught to intubate critically ill patients. However, intubation of hanta patients during the cardiopulmonary phase can actually be detrimental. Also, in general, extracorporeal membrane oxygenation (ECMO) is an intervention of last resort for most critically-ill patients. As the procedure essentially involves hooking the patient up to a heart-lung machine, which has a lot of complications, doctors do not do this unless they have to. But in hantavirus disease, early initiation of ECMO has been shown to significantly improve survival.”
“Another tricky thing about ECMO is that not all hospitals have an ECMO machine… oftentimes patients have to be transferred from one hospital to another because they need ECMO and it is not available where they are.” The ECMO-equipped facility closest to TMC is 170 miles away, at the University of New Mexico Hospital in Albuquerque.
For all those reasons, Dr. Choi said, it is critically important for physicians to know if the patient they are treating has hantavirus or not. The problem is, there is no rapid test for hantavirus disease. The tests have to be sent out to a laboratory and it can take days before physicians receive a test result. “This is where the 5-point screen is such a valuable tool. Although it is not a diagnostic test, it is a very accurate screening tool. Even better, it is readily and widely available, because to perform the screen, you only need a complete blood count (CBC) and a peripheral blood smear…which can be performed in the vast majority of laboratories and clinics. In addition, the CBC and peripheral blood smear are very commonly ordered tests.”
The screen could be particularly crucial for small community hospitals and clinics. “[TMC] took a screen developed by hematopathologists for hematopathologists,” Choi said, “and adapted it so that it could be performed by clinical laboratorians—because hematopathologists don’t exactly grow on trees! Once we heard about the work that TMC was doing, we knew that this was something we wanted to support and advocate for.”
“We started to throw around the idea of teaching this method to other laboratories on the reservation,” Oliver said. She and Mary Choi teamed up to “knock on everyone’s door to see who was utilizing the screening or if they had their own methods of detecting hantavirus in their patients.”
Two years later, they began holding training sessions at a nearby community college; they also trained an entire laboratory at their hospital in late 2019. Plans were to set up other training sessions towards the border towns before spring of 2020.
Then SARS-CoV-2 showed up.
Hantavirus or coronavirus?
COVID-19 hit the Navajo Nation like a sledgehammer. Native Americans in rural areas, as many Navajo are, may have multigenerational and extended families living in tight quarters, with limited access to running water, miles from the nearest healthcare facility. They were particularly vulnerable to a virus that thrives on close contact, at a time when the most common preventives were distancing, frequent handwashing, and testing. By May 2020, the Navajo Nation had surpassed the epicenters—New York and New Jersey—in cases of infection. Even as late as November 2021, the Navah Nation has reported > 37,000 positive cases, and nearly 1,500 confirmed deaths, despite reaching a 70% vaccination rate.
Making things ever more challenging: How do you know whether the patient has hantavirus or COVID-19? The distinction is critical because the disease courses of the 2 infections differ greatly. “The importance of [TMC’s] work was really brought home by the COVID pandemic,” Mary Choi said. “The signs and symptoms of early COVID and hantavirus are really indistinguishable. But the problem is that most people with COVID will live, while most people with hantavirus will die without critical care.”
The overall US case fatality rates are drastically different: 36% to 38% for hantavirus, 1.6% for COVID-19. In Arizona alone, of 81 patients who developed hantavirus (as of 2019), 27 died. In New Mexico, of 117 patients, 51 died.
“The scary part,” said Tarrah Oliver, “was that when patients were flooding our ER with symptoms exactly like those of hantavirus, I kept thinking that it was now up to us in the lab to scrutinize CBC results for any characteristics of hantavirus because our locum providers and permanent providers would likely not have hanta on their minds right now to suspect it.”
“Once COVID hit Navajo Nation, we really worried about how clinicians were going to distinguish between the two disease entities and worried about possible excess deaths of hanta because they were mistaken for COVID-19,” Choi says. “Unfortunately, in the spring of 2020, 2 fatal cases of hantavirus were reported. Their deaths were initially thought to be due to COVID, but later testing showed that they both died of hantavirus. We knew that we had to study whether the 5-point screen could distinguish between hantavirus disease and COVID.”
They conducted the comparison study at TMC and Emory, in Atlanta. TMC, as a small hospital, might not get many COVID cases while Emory, a large hospital system, had many COVID cases but rarely hantavirus cases (Box).
The researchers found that the screen did indeed work as they had hoped. No matter who performed the screen, the demographics of the population screened, or when in the COVID-19 disease course the sample was taken, individuals positive for COVID-19 received a low score on the screen. None of the participants who were positive for COVID-19 demonstrated all 5 hallmarks of hantavirus infection, and only 3 patients received a score of 4.
The screen was most accurate when the specimen was collected during the cardiopulmonary phase. Before the cardiopulmonary phase [BOX], there is a short febrile prodromal phase in which the platelets are starting to drop but aren’t low enough to be considered thrombocytopenic. Hematocrit and hemoglobin levels are still normal, and immunoblasts or plasma cells haven’t been released into the blood yet. “A patient’s score is likely to be pretty low or intermediate,” Tarrah Oliver said. “In the febrile prodromal phase, the patient will have chills, fever, headache and myalgia lasting 3 to 6 days, which might be written off as the flu or even COVID-19, especially if a provider is not familiar with the endemic regions of the Navajo Nation.”
“When we found that the screen could distinguish between the 2 diseases,” Choi said, “we worked frantically to write up the findings and publish so that healthcare providers would be aware of the value of this tool.”
“I couldn’t be more excited that the word is getting out in the medical community,” Oliver said. They plan to share the information as widely as possible, booking local radio spots, for instance. “We’re trying to disseminate our research across our partners on the reservation.”
The results of the research were recently published in the American Journal of Clinical Pathology. “Our next follow-up research will be an inter-rater reliability between TMC’s 2-year and 4-year-degree medical laboratorians and Emory’s pathologists performing the 5-point hantavirus screen on the same slides. We want to show that rural hospitals without the expertise of pathologists can perform this screen for their patients in a timely manner and still get the same outcomes.”
Lastly, and the most exciting, Oliver said, is putting that training manual she created to wider use. In addition to all the case studies she collected, analyzer printouts, and PowerPoint slides about the epidemiology, the manual includes a procedure, billing codes, and layout of what it looks like on certain medical record software that most Indian Health Service hospitals use. “With the manual, we may be able to expand our reach, so I won’t need to travel,” Oliver said. “We could use Zoom to reach further and I could explain it all while they have the manual right in front them.”
So far, nearly 200 screens have been performed at TMC. Four cases of hantavirus disease have been identified. The screen has proved successful, but for Oliver, there’s a personal reward. “I heard stories as a kid of relatives and friends succumbing to this mystery flu in the 1990s and how our parents protected us from it,” she said. “Now I feel like it’s my turn to take care of my family and friends from both hantavirus and COVID, our current ‘mystery flu.’ … I’ve realized that now I’m doing this for our people, the Diné (Navajo) people.”
This article offers some background and follow-up to Hantavirus Disease and COVID-19: Evaluation of the Hantavirus 5-Point Screen in 139 COVID-19 Patients