Hantavirus Pulmonary Syndrome in the Spotlight: Understanding Risks After Betsy Arakawa’s Tragic Death

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The recent passing of Betsy Arakawa, wife of the late actor Gene Hackman, due to hantavirus pulmonary syndrome (HPS) has brought renewed attention to this rare but serious disease. HPS is a severe respiratory illness caused by hantaviruses, which are transmitted primarily by rodents. Given the challenges in diagnosing and treating HPS, it is important for clinicians to stay informed about its risks, symptoms, and management.

Overview of Hantaviruses

Hantaviruses are primarily spread by rodents’ body fluids and excrement. People contract hantavirus mainly through the inhalation of virus-contaminated air. Most hantaviruses found in the Americas can cause HPS, with the Andes virus in South America known to have cases of person-to-person transmission.

The Sin Nombre virus, a leading cause of Hantavirus Pulmonary Syndrome (HPS) in the U.S., is primarily carried by deer mice, which are widespread across much of the country, especially in the Southwest. While deer mice are the main reservoir, other rodents can also carry hantaviruses. In the Northeast, white-footed mice are linked to hantavirus infections, while in the Southeast, cotton rats may carry a strain that causes HPS.

Exposure Risk Factors

Individuals at risk for HPS include those in contact with infected rodents or their droppings, urine, saliva, or nesting materials. Rodent infestations in and around homes remain the primary source of exposure. Activities such as cleaning homes, cabins, or sheds where rodents are present increase the risk of exposure. Cases predominantly occur in rural areas where rodents thrive in forests, fields, and farms.

Transmission

Humans can contract hantavirus through contact with urine, feces, or saliva of a rodent carrying the virus:

• Inhalation: Breathing in air contaminated with virus particles from rodent urine, droppings, or saliva.
• Direct Contact: Touching surfaces contaminated with these excretions and then touching the mouth or nose.
• Bites: Although rare, bites or scratches from infected rodents can transmit the virus.
• Contaminated Food: Consuming food contaminated with hantavirus.

While pets do not contract hantavirus, they may transport infected rodents into human living spaces.

HPS doesn’t spread between people, but the virus can survive on surfaces for hours or even days. Care must be taken during cleaning, as sweeping and dusting can aerosolize infectious particles, increasing the risk of inhalation, which is thought to be the most common pathway of infection.

Symptoms and Severity

Symptoms of hantavirus typically develop 1-8 weeks after exposure to rodents or rodent droppings. HPS initially presents with non-specific, flu-like symptoms, including fever, fatigue, muscle aches, headaches, dizziness, nausea, and cough. While many infected individuals recover within 1-2 weeks, some may experience worsening conditions 4-10 days after symptom onset, progressing to severe respiratory illness. As the disease progresses, coughing and shortness of breath may occur as the lungs fill with fluid. HPS is fatal in nearly 4 out of 10 people who are infected.

Early Identification to Improve Outcomes

While there is currently no specific treatment for HPS, early identification is critical for improving outcomes. Health care professionals should follow the identify, isolate, and inform model. This includes using a universal symptom and travel screen at health care points of entry to facilitate the identification process. Using a broad approach to the travel screen to include travel within the United States and new high-risk exposures can be useful for early identification of patients with HPS.

Diagnosis and Testing

Diagnosing HPS can be difficult due to its non-specific early symptoms, which resemble infections such as influenza, Legionnaires’ disease, leptospirosis, mycoplasma, and Q fever. Laboratory testing is required for confirmation.

Diagnostic Approach

Clinicians should evaluate:

• Symptom presentation and patient history of rodent exposure
• Testing guidelines and methods to confirm hantavirus infection
• How to request diagnostic support from CDC if needed
• Reporting requirements for hantavirus cases

Laboratory Testing

CDC and designated laboratories—including state labs, public health labs, and commercial labs—use an Enzyme-linked immunosorbent assay (ELISA) test to detect antibodies and confirm hantavirus infections.

A hantavirus-positive case is reported based on national guidelines, which consider clinical symptoms (HPS or non-HPS) and lab results such as:

• Positive IgM test
• Rising IgG antibody levels
• Positive immunohistochemistry
• Positive PCR test

Clinicians should report suspected cases to their local or state health departments and may contact the CDC Emergency Operations Center at 770-488-7100 for consultation and testing support.

Treatment and Patient Management

Because there is no specific antiviral treatment for HPS, early intensive medical care is essential. Early patient management should include:

• Continuous cardiac monitoring
• Careful fluid administration
• Supplemental oxygen and mechanical ventilation as needed
• In severe cases, extracorporeal membrane oxygenation (ECMO) can help patients breathe and has an 80% survival rate
• Appropriate broad-spectrum antibiotics, fever reducers, and pain relievers

Prognosis and Recovery

• Most deaths occur within 24-48 hours after the onset of cardiopulmonary symptoms.
• Severe cases often have high levels of lactic acid in the blood and poor heart function.
• Fluid buildup in the lungs is common, but major organ failure is rare.
• Survivors often experience a polyuric phase during recovery.

Minimizing Risk: Practical Measures for the Public

To minimize the risk of exposure to hantavirus, individuals should take the following measures:

• Open and air out buildings such as cabins and sheds, and other areas that may have provided shelter or food, before entering.
• Employ effective trapping methods to eliminate rodents from the premises.
• Seal off potential entry points where rodents may enter homes or shelters.
• Store food in rodent-proof containers.
• Before cleaning, treat nests, droppings, or contaminated surfaces with a disinfectant solution.
• Avoid sweeping up rodent droppings, shaking rugs, or dusting untreated contaminated surfaces to prevent the dispersal of viral particles into the air.
• When handling nests or contaminated articles, wear gloves, practice proper hand hygiene, and refrain from touching your face to minimize the risk of exposure

Learn more about HPS: https://www.cdc.gov/hantavirus/hcp/clinical-overview.