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Research in extraordinary times of war

Great scientific success with scarce resources. Is money issue a crucial point?

Research in extraordinary times of war

Mirsada Hukić ESCMID Online Lecture Library

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THE WAR

The war in Bosnia and Herzegovina during 1992 to 1995 was particularly brutal.

During this war there was no respect for either human beings or the rule of humanity. There was no

difference among civilians, children and old people from soldiers.

The weakest, children and women, have suffered most. Human life was not worth much and the killed were

mentioned only as numbers! ESCMID Online Lecture Library

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In such circumstances, the imperative was to survive! ESCMID Online Lectu

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• The war had a strong impact on the country’s economy and public health system and was associated with changes in socio-economic, ecological and environmental factors.

• In the war and post-war period, the conflict was the leading cause of disability, premature death and injuries.


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Infectious diseases

• A growing change in risk profiles for the infectious diseases was observed.

• During the war and post-war period we were faced with outbreaks of disease unknown in B&H, with severe clinical presentation and high mortality.


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Emerging and reemerging diseases

• The emergence of unknown diseases, in addition to killing, wounding, starvation and fear, was an additional factor for the occurrence of panic.

• We researched several outbreaks including: – hemorrhagic fever with renal syndrome (HFRS),

– tularemia,

– rickettsiosis,

– sandfly fever Toscana, and

– Trichinella infection among the Muslim population, which simultaneously occurred in Bosnia in 1995,

– Lyme diseases.

• This presentation will focus on hemorrhagic fever with renal syndrome (HFRS). ESCMID Online Lectu

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• Without sufficient medicines and sanitary materials, working without electricity and water, it was the task of small number of health professionals to help the wounded and sick and to prevent the spread of the disease.


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There were no conditions for quality routine work, and especially not for research.

The deliberate destruction of libraries


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THE EPIDEMICS

• The epidemic of hemorrhagic fever with renal syndrome broke out among soldiers in northeast Bosnia and Herzegovina in 1995.

• The epidemic involved more than 1000 soldiers who were of similar age, lived in identical conditions in military trenches, and ate the food from the same cauldron.


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THE CHALLENGES

• The challenges for the health care professionals were:

– Provide assistance to persons suffering

– Put under the control of the spread of the epidemic

– Determine the cause of the epidemic ESCMID Online Lectu

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Challenges

• Careful observation and analysis of epidemic pointed out some oddities and incongruities.

• An intriguing characteristic of this epidemic was really huge difference in the clinical signs and symptoms of HFRS.

• One group of patients had a mild clinical form while others had very severe disease with fatal consequences.


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Challenges

• This motivated us to think about researching this phenomena.

• We realized that we had to analyze the etiological agent of infection (expected Hantaviruses) and their reservoirs if we wanted to find the cause of the outbreak and difference in the clinical presentations of disease.


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DECISION

• We started to research:

– between military opposing sides

– in the area with a large number of mines

– with scarce resources.


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Networking

• We needed help!!!

• Our approach was to establish the network of experts in the field of Hantaviruses.

• Thanks to the help of World Health Organization, we came in contact with the experts from Europe and United States of America.


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Networking – Swedish team - Bo Niklasson and

Ake Lundvikst, The Swedish Institute for Infectious Disease Control,

– USA team - Kelly McKee and James Le Duc

– Belgian team – Paul Hayman and Jan Clement, Queen Astrid Military Hospital

– Medical teams of U.S. military bases "Eagle" Tuzla B&H

– The Nordic battalion located in Tuzla, B&H. USA team


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Collaboration

• They introduced us to the skills of hunting rodents and supplied us with the necessary equipment for hunting, processing hunted animals and with tests for laboratory diagnostics.

• The Nordic battalion participated in the transportation of the biological material between B&H and Sweden.

• The USA team transported some samples to CDC Atlanta.


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RESEARCH

• Our research was focused in three main directions:

– Clinical research

– Epidemiological and epizootical research

– Virological investigations


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The patients with clinical symptoms resembling

HFRS were serologically tested for acute

hantavirus infection.

We have followed clinical signs and symptoms of disease.


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Epidemiological and epizootical research

•Data on disease distribution, incidence and public-health activities have been collected. •The rodents were collected in the area.


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Animals were collected with live-traps


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Animals were identified by

morphometric methods


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Sampling Blood, lungs and kidneys were taken. Sera of animals were examined for the presence of antibodies reactive with the Dobrava, Puumala, Seoul and Hantaan viruses by using indirect imunofluorescent test (IIF). Kidneys and lungs of the animals were examined for the presence of Hantaviruses. ESCMID Online Lectu

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RESULTS


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1. Apodemus flavicollis

2. Apodemus sylvaticus

3. Apodemus agrarius

4. Clethrionomus glareolus

5. Chionomys nivalis

6. Dinaromys bogdanovi

7. Sorex araneus

8. Pytimus subterraneus

9. Mus musculus

10. Mycrotus arvalis

11. Rattus norvegicus

We have caught 745 animals. Species of rodents were determined as follows:


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Detection of antibody in the rodent’s sera:

• To PUUMALA

Myodes glareolus

Chionomys nivalis ?

Dinaromys bogdanovi?

Mycrotus arvalis (PUU=Tula ?)

• To DOBRAVA

Apodemus flavicollis ESCMID Online Lecture Library

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BOSNIA AND HERZEGOVINA DOBV/Tuzla 43

• Viral RNA was isolated from the lungs of Apodemus flavicolis.

• Partial S segment sequence originating from Bosnia-Herzegovina was grouped together with the Slovenian strains forming a distinctive phylogenetic lineage.


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During the epidemics in 1995 in Bosnia and Herzegovina, our results showed that at

least two different hantaviruses each carried by a different rodent species circulated in

the area: - the murine Dobrava (DOB), and

- the avricoline Puumala (PUU) viruses.

Hukić M, Kurt A, Torstensson S, Ludkvist A, Wiger D, Niklasson B. Outbreak of haemorrhagic fever with renal syndrome in north eastern Bosnia. Lancet 1996; 347:56-57. Lundkvist A, Hukić M, Hurling J, Gilljam M, Nichol S, Niklasson B. Puumala and Dobrava virusses cause hemorrhagic fever with renal syndrome in Bosnia-Herzegovina: Evidence of higly cross-neutralizing antibody responses in early patient sera. J Med Virol 1997; 53:51-59.


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During the war in B&H (1992-1995), more than 500 patients, most of them soldiers exposed to the fields

in northeast Bosnia, were hospitalized with acute Hantavirus disease due either to Puumala virus

(PUUV) or Dobrava virus (DOBV).


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Serological Diagnosis

• We have found that the acute- or early convalescent-phase sera, even when drawn as late as 3 weeks after the onset of disease, could not be used for typing of the causative Hantavirus.

• Moreover, although several acute-phase sera showed the highest FRNT titer to Hantaan virus, convalescent sera from these patients in all cases showed high specificity for Puumala or Dobrava viruses.

• This phenomenon, interpreted as a cross-neutralizing primary antibody response, makes several earlier reports concerning causative agents of HFRS questionable.

Lundkvist A, HUKIĆ M, Harling J, Gilljam M, Nichol S, Niklasson B. Puumala and Dobrava virusses

cause hemorrhagic fever with renal syndrome in Bosnia-Herzegovina: Evidence of higly cross-neutralizing antibody responses in early patient sera. J Med Virol 1997; 53:51-59.


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THIS STUDY WAS THE BASIS FOR ESTABLISHING GUIDELINES FOR INTERPRETATION OF SEROLOGICAL TESTING OF HANTAVIRUS INFECTION.

Impact on the serological diagnosis


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In patients sera who had symptoms HFRS, and negative for HTV, antibody to Sandfly fever virus Toscana (SFTOS) or for typhus group Rickettsia was detected Hukić M, Salimović-Bešić I . Sandfly – Pappatachi Fever in Bosnia and Herzegovina: the new-old Diseases. Bosn J Basic Med Sci. 2009;9(1);p39-43.


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CLINCAL COURSE OF HANTAVIRAL DISEASES

• The spectrum of clinical manifestation of the disease ranges from mild illness to a severe form with fulminant hemorrhagic fever and death.

• Asymptomatic or non-specific mild infections result in underestimated number of Hantavirus infections.

• Hantavirus seroprevalence was 7.4% in the endemic region of B&H and 2.4% in the non-endemic region of B&H

Graph 1. Geographic map of B&H showing the distribution of study population.

High endemic region

Hukić M, Nikolić J, Valjevac A, Šeremet M, Tešić G, Markotić A. Serosurvey reveals Bosnia and Herzegovina as a Europe’s hotspot in Hantavirus seroprevalence. Epidemiol Infect. 2010;138(8);p1185-93.


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Storing samples and data

• During the war, we collect and archive of human and animal samples at -80⁰C for future research.

• We also store copies of case histories of hospitalized patients.


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The post war activities We continuously researched clinical characteristics of

PUUV and DOBV infections in acute, early convalescent and reconvalescent phase of the disease over a 10 year period.

We analyzed the clinical course and the outcome of patients with HFRS caused by these two viruses and evaluated whether it left long-term consequences on kidney function.

We worked on lab diagnostic of HTV infection.

We informed professional and scientific public about our results.


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Tulumovic T, Imamovic G, Mesic E, Tulumovic A, Zerem E, Hukić M. Hemorrhagic fever with renal syndrome in Bosnia: did it leave long-term consequences? Nephrology (Carlton). 2010;15(3);p340-3.

Hukic M. Hantaviruses in Bosnia and Herzegovina: microbiological, epidemiological and clinical aspects. Radovi, Odjeljenje medicinskih nauka, Centar za medicinska istraživanja, ANUBiH. 2002;30 (1);p175-182.

Hukić M, Muzaferović Š, Tulumović D, Čalkić L, Šabović S, Karakaš S. Puumala and Dobrava viruses in the northeastern and central regions of Bosnia. Acta Med Croatica. 2003;(57);p373-380. Tulumović D,

Hukić M, Mešić E, Šabović S, Tulumović A. Ultrasound findings on abdominal organs in the acute phase of hemorrhagic fever with renal syndrome. Acta Med Croatica. 2003;(57);p427-431.

• Hukić M, Valjevac A, Tulumovic D, Numanovic F, Heyman P. Pathogenicity and virulence of the present hantaviruses in Bosnia and Herzegovina: the impact on renal function. Eur J Clin Microbiol Infect Dis. 2011;30(3);p381-5

Biel SS, Mantke OD, Lemmer K, Vaheri A, Lundkvist A, Emmerich P, Hukic M, Niedrig M. Quality control measures for the serological diagnosis of hantavirus infections. J Clin Virology. 2003;(28);p248-256.

Smajlović L, Davoren J, Heyman P, Cochez C, Haas C, Maake C, Hukić M. Development and optimization of a PCR assay for detection of Dobrava and Puumala hantaviruses in Bosnia and Herzegovina. J Virol Methods. 2012 Jun;182(1-2):37-42.


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We have hunted the rodents every year since 1995! We have done continuing epizootiological and epidemiological surveys.


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We worked very hard and collaborated with friends

around the World

Ho-Wang Lee

J Arikawa

Paul Hayman

Forestry workers and Mirsada

Helen de Rode


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CONCLUSION

• In conclusion, great scientific success is possible with scarce resources, even in extraordinary times of war.

• In this condition, it is essential to have: – analytical skills, – careful observation, – good idea, – hard work, – high risk, and – cooperation with international partners.

• If you have all of the above, money is important but not crucial because a good idea will get recognized and supported. ESCMID Online Lectu

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Univerzity Clinical Center Tuzla, B&H Ministry of health, Tuzlansko-podrinjski Canton, B&H

World Health Organization, Office in B&H

Swedish Institute for Infectious Disease Control, Stockholm, and Microbiology

and Tumor Biology Center, Stockholm, Sweden Medical teams of U.S. military bases "Eagle" Tuzla, B&H

The Nordic battalion located in Tuzla (1992-95), B&H Queen Astrid Military Hospital, Brussels, Belgium Federal ministy of science, culture and sport, B&H

University Clinical Center Sarajevo, B&H Swiss National Science Fundation, Department of Clinical Research, Medical

Faculty University of Bern, Switzerland

Research was suported by:


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