South American haemorrhagic fevers

Community education and awareness:

• Patients should avoid contact with other people if they have, or think they have, SAHF.

• Patients should seek immediate advice from a healthcare professional if SAHF is suspected.

• If a patient has suffered from SAHF they should discuss with their doctor if there is a risk of sexual transmission of the infection during the recovery period. If they are unsure then barrier contraception (condoms) should be used until testing of semen reveals the virus is not present.

• Patients who have survived Argentine haemorrhagic fever or Bolivian haemorrhagic fever should contact their doctor immediately if they develop a further fever or symptoms such as headache, tremor, or loss of balance and coordination during the 3 months following discharge from hospital.

Sexual health and pregnancy:

• Virus persistence has not been well described in survivors of the SAHFs. Junin virus has been isolated from blood, urine, and mother’s breast milk during the acute phase of the disease, but there is no documentation of virus identification in bodily fluids in the convalescent or post-convalescent period.[5]Enria DA, Briggiler AM, Feuillade MR. An overview of the epidemiological, ecological and preventive hallmarks of Argentine haemorrhagic fever (Junin virus). Bulletin Institut Pasteur. 1998;96:103-114.​ In patients who develop late neurological syndrome following survival of Argentine haemorrhagic fever, the cerebrospinal fluid is positive for antibodies to Junin virus, but Junin virus itself has not been isolated.[4]Enria DA, Briggiler AM, Sánchez Z. Treatment of Argentine hemorrhagic fever. Antiviral Res. 2008;78:132-9. https://pmc.ncbi.nlm.nih.gov/articles/PMC10245337 http://www.ncbi.nlm.nih.gov/pubmed/18054395?tool=bestpractice.com Sexual transmission has been described in the context of Argentine haemorrhagic fever, although it remains a rare event.[34]Enria D, Mills JN, Bausch D, et al. Arenavirus infections. In: Guerrant RL, Walker DH, Weller PF, eds. Tropical infectious diseases: principles, pathogens, and practice. 3rd ed. Amsterdam: Elsevier; 2011:449-461.[53]Briggiler AM, Enria DA, Feuillade MR, et al. Contagio interhumano e infeccion inaparente por virus Junin in matrimonios del area endemica de fiebre hemorragica Argentina. Medicina (Buenos Aires). 1987;47:565.​ It has not been described in the context of the other SAHFs, but this may be related to the relatively few cases reported for some diseases. On these grounds condoms should be advocated in male survivors until serial testing of semen demonstrates absence of the virus, particularly in the case of Argentine haemorrhagic fever. Due to the presence of Junin virus in breast milk during acute disease, the potential for transmission to a breastfeeding infant must be considered.[5]Enria DA, Briggiler AM, Feuillade MR. An overview of the epidemiological, ecological and preventive hallmarks of Argentine haemorrhagic fever (Junin virus). Bulletin Institut Pasteur. 1998;96:103-114.​ While no cases have been described, interruption of breastfeeding should be considered during the acute disease and until the breast milk is consistently demonstrated to be free of virus through reverse transcription-polymerase chain reaction testing. Vertical transmission of SAHFs has not been described, but has been described in the case of other viral haemorrhagic fevers. On this basis children born to women infected during pregnancy should be monitored for the development of symptoms following delivery and for the duration of the incubation period.

• Ribavirin is teratogenic and its use is contraindicated in pregnancy. Women of childbearing age who receive ribavirin as treatment should be advised not to conceive during, and for at least 4-6 months following, treatment and should be provided with effective contraception during this time. Men who receive ribavirin should be advised to use effective contraception during (and for 6-7 months following) treatment, and if their partners are pregnant. Ribavirin should also be avoided in women who are lactating and wish to continue breastfeeding as there is insufficient information on expression in breast milk and effect on the infant. However, in this context, the potential benefits of ribavirin to the patient must be weighed against the risks to the infant of stopping breastfeeding.

Travel:

• Individuals travelling to or living in endemic regions should be aware of the potential risks of infection if they are involved in agricultural work, or if they are in frequent contact with rodents, including rodent infestations, where they are dwelling. They should be informed that if they develop a fever they should discuss their symptoms with a local healthcare professional to determine if their symptoms are consistent with one of the SAHFs. The earlier treatment is sought, the better the prognosis. If they develop symptoms on their return to their home country, they should mention the regions they have travelled to when attending any healthcare facility, prior to any physical contact or examination by a healthcare practitioner. They should also inform the healthcare practitioner if they are aware of any contact with one of the SAHFs, or if they have undertaken agricultural work, or knowingly been in contact with rodents.