E21: The public health brief: Hantavirus

Welcome to Public Health Briefs — a new series from EMERGE in EM where we break down the public health stories shaping our world through the lens of emergency medicine, critical care, and frontline science.

In this episode, we tackle the growing public concern surrounding hantavirus after recent viral headlines and online speculation sparked fear across social media. Joined by infectious disease specialist Dr. Yassin, I take a deep dive into what hantavirus actually is, how it spreads, why certain strains raise concern for person-to-person transmission, and what clinicians and the public truly need to know.

We discuss rodent exposure, incubation periods, cardio-pulmonary syndrome, ECMO considerations, diagnostic challenges, public health response, quarantine recommendations, and the dangers of misinformation during emerging infectious disease events.

This conversation is not about panic — it’s about perspective, preparedness, and evidence-based medicine.

Because in public health, the goal is always the same: awareness over fear, science over speculation, and protecting communities through accurate information.

Thank you for listening to Public Health Briefs on EMERGE in EM.

Transcript

Mohamed 0:00

Dr. Yassin please tell the audience, a little bit about you and what you do and where you're from.

Dr. Yassin 0:05

Thank you so much for interviewing me. I'm a professor of medicine at the School of, Medicine at the University of Pittsburgh and School of Public Health. I, hold a couple of, academic appointments, but most of my work is in infection prevention, and I chair the quality committee at UPMC Mercy.

Mohamed 0:21

Wow. A lot of responsibilities. And you take care of patients, right?

Dr. Yassin 0:25

Of course, that's every day.

Mohamed 0:26

you know what? Over the past few days, social media has absolutely exploded with conversations about hantavirus, after the cruise ship situation, and suddenly everybody became experts in hantavirus pathophysiology, transmission, and even people started to label it as the next pandemic, the worst-case scenario, Everybody is gonna get it from a simple, person-to-person interaction in the grocery store or on the streets. you know what? after I saw all of this, I was like,"You know what? I'm not gonna do it by myself. I'm gonna bring an ally. I'm gonna bring my brother over here, who is an infectious disease specialist, to discuss this topic and to provide the audience not only with accurate information, but also a realistic background of what this virus means, the exposure, the transmission, the pathophysiology, and ultimately the treatment." And let's start from the beginning. Let's start from the basics, to someone who has no idea about what hantavirus is. what is it exactly?

Dr. Yassin 1:36

So it's a viral infection. It's an RNA virus, like many RNA viruses like the flu and COVID. So it, it makes different versions over the years, so you can have different variation and mutations. It causes two similar disorders in different parts of the world, one that predominantly affects the lung. The other one has some fever as well as kidney involvement. But regardless, both the different flavors that we have has to do with rodents, has to do with mice.

Mohamed 2:10

That comes down now to exposure. So we have different strains of the virus. so European, Asian strains are different, or I guess they, cause different presentation that the American strain. And I, obviously I can't help myself but ask you, why is that?

Dr. Yassin 2:28

So the receptors for different viruses in different organs in the body predominate really the symptoms or the involvement of the organs. and the predilection we see in many diseases in similar fashion. You talk about Leishmania, for example, you're talking about different bacteria. Yeah, d-different strains affect different organs. That's not unheard of. the common issue that still persists with this hantavirus is rodent exposure. we always talk about cleanliness and keep things tidy and clean. I think that's incredibly important everywhere.

Mohamed 3:03

And what kind of rodent exposure exactly are we talking about?

Dr. Yassin 3:06

So there's different types of rodents, of course. They're not the same, but generally speaking, you can have that by direct transmission. You have the little mouse in your hand, you hold it, and then you c- this, you can get you the infection. But most of the infection we see are from inhalation. So there is an area that has a lot of mice. I'm talking as a simple example that you and I could see every day, where e-every one of us has a house maybe, and there's a little shed in the backyard. You go in the spring to clean it, get the stuff out, and all of a sudden you see some droplet from the mice, and there's no much good aeration. You inhale that, that could be enough to get you the disease. And you can think about the discussion about the cruise ship, that they went to this place where there is a mine f- the, a field mine where they have all this, infected stuff from the rodents and stuff. People breathe that, inhale that. That is definitely the most common cause, of getting the infection. And really, when you talk about rodents in general, like leptospira, plague. There's so many other disorders that get from that. Most of this, the most effective way of transmission is actually inhalation or aerosol, that just you breathe in and you get it. Of course, through skin cuts or other problems like direct holding the animal itself. sometimes you have a vector transmission in between, and that's probably true for plague, where you have a flea or even a tick comes, to the mouse or the rodent and then comes to bite us, and we get the infection that way. But for hantavirus, you're talking about an aerosolization Is the most common cause.

Mohamed 4:51

Tell us a little bit more about the presentation of the, of the illness initially. How does it present in an infected person?

Dr. Yassin 4:57

So if you have, a person coming with a pneumonia, as to simplify that will be probably very similar to what in hantavirus pulmonary disease, where you have cough, shortness of breath, fever. the issue here is the long prodrome or the long incubation period where a person would have weeks of symptoms. When you talk about flu, one day you're not feeling great, and then next day you're sick. For that one, you could have maybe two or three weeks, you're not feeling great, and then boom, you're getting worse, severe pneumonia, and you're really at risk of dying from this disease. that to me is the most common thing that we see clinically. not every case is symptomatic, but the majority of them, you have a longer incubation period or longer period of not feeling well, followed by severe respiratory symptoms.

Mohamed 5:51

So the incubation period is not viral pneumonia or any upper respiratory symptoms within days, three to five days, max seven days. So are we talking about months, thirty, forty days? What is the window exactly?

Dr. Yassin 6:03

So the cruise ship, they ask them to stay in, quarantine or isolation for forty-five days, but the most common incubation period, we're talking about two to three weeks. There's a lot of reports that goes up to eight weeks. So I think when you have an outbreak or a cluster, you really wanna make sure that you don't let people go into the community and infect others. And I would say that makes sense, but the majority, clinically, of the cases is talking two to three weeks from the exposure.

Mohamed 6:33

Okay. Wow. So it's a long quarantine period before being able to socialize again with people. So just going back a little bit, you talked about these different types of strains. So you mentioned Europe, Asia, have this strain that can cause a specific disease etiology, which is the, hemorrhagic fever with renal syndrome. And then in the Americas, we have the cardiopulmonary syndrome commonly, right? That was the most common kind of geographic or ecological presentation. Tell us maybe more about first the Asian-Eur-European version. how does that infection present like?

Dr. Yassin 7:12

So most of these infection follow the path of the, transmission via inhalation from the rodent, secreta. You're talking about the stool or the urine or other stuff. When we talk about the New World, you can have the Andes virus that actually could be transmitted through human to human, and that's probably the big issue that we're talking about for this particular ship or the cruise ship. still people think it's not the biggest way of transmission, but it does happen. The reason for the hemorrhagic fever and the kidney is not very clear in my mind why, but it is a specific observation that we knew about that, the Old World disease versus the New World disease. Most of the people with this hemorrhagic fever, they actually also get a very sick, course or very severe course out of that. But it just a little bit different than the pneumonia pattern that we see mostly in the New World or the Americans. in this particular cruise ship, I think the, they had around thirty percent mortality, and this number seems to be steady through even both types as well as the current cluster that we're talking about.

Mohamed 8:27

Yeah. So just to be clear, you talked about a specific strain. It's called, I think it's called the Andes strain in South America, where, the first person of contact was I guess was in the Argentinian kind of, environment and got it from a rodent, but that specific strain, the Andes strain, is transmitted from person to person. That's why it's creating all this mass hysteria and social media, misinformation about it exactly. But when we talk about person-to-person transmission, this is very unique. It has to be really close proximity, right?

Dr. Yassin 9:03

Of course. So a lot of people even say an intimate relationship, like sleeping together in the same room or having intimate relation in any way, it's not like a casual contact. But, just to be very clear, with intense relationship close to each other, things can happen out of the normal. So people always extrapolate that and saying that,"If I'm walking somewhere and that person has it, I'm gonna get it." I don't think that's the case at all. And, what's common is still common. What's not common is still not common. a-again, I'm not taking you away from the discussion on hantavirus, but if you talk about cholera, for example, cholera is not transmitted human-to-human mostly. It's not, but it can be. So when you have a intense exposure, things could go out of the normal, but that's really not the case usually, even with the Andes strain. And I think this was reported in the New England Journal of Medicine even before this exposure, talking about how human-to-human transmission could occur, and there is a significant number of that, maybe 20% of a previous exposure were human-to-human. But if you look in the details of this, it's still very close contact, almost like a husband and wife, or people are just really close to each other for extended periods.

Mohamed 10:22

So you're talking about, transmission via saliva. Can it be transmitted via intercourse, like sexual intercourse or just saliva?

Dr. Yassin 10:29

it is reported that way, too, but I'm not sure if it, the issue is the sexual transmission or the issue is actually the close to each other mostly. And, the saliva is not a very strong way of transmission. It is reported, and actually it is reported also from the saliva of the mouse, too, or the rodent. So when you pe- when people hold it in their hand and they salivate or lick their hand, you can get that, too. So it could go either way, from the human or from the rodent.

Mohamed 11:00

Not very appetizing at all. So that, that brings me to an, a different question, which, in terms of pregnancy and lactation, can it be transmitted by breast milk, and can it be transmitted from, the mother to the baby?

Dr. Yassin 11:16

have enough information to answer that question, honestly. but generally speaking, when we don't know, we always say if a woman is pregnant and has exposure or sick with hantavirus or other viruses, we usually refrain from breastfeeding. That's a general rule, but I do not know specifics about the transmission itself

Mohamed 11:40

So general rule, avoid, secretions or contact with secretions, including breast milk. Now, the pathophysiology, is very intriguing to me, right? This resembles a systemic inflammatory response, and specifically, it attacks endothelial cells in, kidneys, lungs, hearts. all, all kind of things happen when you attack the endothelial cells and cause this increased permeability, so there is increased leak of fluid and f-fluid shifting between the intravascular and extravascular system. So when it comes to that, what are some of the symptoms that we can see early based on this endothelial injury?

Dr. Yassin 12:25

So this also is not a specific phenomena with the hantavirus particularly. We see this in a lot of things and, you're obviously very experienced when it comes to emergency medicine and critical care, and you've had a lot of cases yourself. And in some cases, we would say be careful with the fluids or be generous with giving intravenous fluids to resuscitate a person. So this one disease, you gotta be very careful and make sure you don't give a lot of fluids'cause pulmonary edema would happen faster. And the leaking, as you exactly said, is very true. But, I don't think it's, specific for this particular virus. a lot of viruses, even malaria, for example, follow the same path where being very careful with the fluid resuscitation is a key to actually saving patients. We talk about the US, you can intubate a lot of people in the critical care, but in many parts of the world, critical care beds and intubation is very limited, so putting somebody in overload means you probably would kill him. So your point is very well taken as prognosis, as outcome of those patients for sure. I just don't find it really pathognomonic or specific for that virus. It just fits unfortunately a lot of these diseases.

Mohamed 13:39

Yeah, like you said, the initial symptoms are pretty vague, like any other respiratory illness, headache, muscle aches, fever, chills, nausea, vomiting, some abdominal pain. The intensity of the abdominal pain is very interesting to me because it can actually mimic an acute abdomen, so people think this is a surgical emergency, and they get imaging, and they find nothing. That's also very interesting to me, too. the other thing when you mention about this, what we mentioned about this endothelial leak, they come in, let's say the patient comes in to us by EMS, or they come in by themselves after the initial prodromal symptoms. And by the way, let me ask you a question. I know I'm backtracking, but after the prodromal symptoms, is there a, a convalescent period, or do they jump from the prodromal symptoms to actual disease presentation?

Dr. Yassin 14:28

So not every case will become symptomatic. A lot of people get exposed. They may get serology or testing positive, but not much clinical symptoms. We talked about the incubation period, talks about two to three weeks. So between the prodrome to ma- actual manifestation, that could be really protracted. So I don't think it happens in most of the cases right away. That takes a little bit of time. your point again is really b- very interesting to me because i- imagine yourself a primary care physician or an urgent care physician seeing a patient with coughing, shortness of breath, not feeling well. How many diseases could fit that? Or even if they tell you,"My stomach hurts, can you tell me w- what do I have?" Would you think of hantavirus? Would you ask about rodent exposure? I'm not sure if every physician or every provider would do that. And, the amount of testing available even is not very common, so it just becomes a complexity in making the diagnosis. I think if you do make the diagnosis early, you can actually find the case, you can observe, you can interact, and you could really fix it, or at least conservatively manage the patient till you get them safer and better. But unfortunately, if you delay or miss, that will be more problems for sure.

Mohamed 15:52

I tell you, right now, I would. I would ask everybody in the ED with viral symptoms,"Did you kiss a rat? Yes? All right, let's go." That's gonna be part of my HPI. Make sure, kissing rats, risk factor. But seriously, though, if they come into you with those symptoms, sure. But then now the story is consistent. They were traveling, they just came from a cruise ship. They, were exposed somewhere. Maybe they come from, an endemic area, of hantavirus. Is there anything specific on examination besides the history that we can, rely on to say,"You know what? This is likely hantavirus." Is there anything we can see?

Dr. Yassin 16:32

So we, we see a lot of abnormalities in the metabolic panel, talking about the liver function, the liver enzymes, sometimes kidney function, CPK, lactate, all the stuff that we see with sepsis You could see some of that. Even the blood components could be like, change in the platelets, change in the white cells. You could see some of that for sure. but if you ask me like,"What would make you make the diagnosis?" Your clinical suspicion and probably confirmatory testing, which is usually serology, and you could do a PCR. The problem I have with the serology is none of that is FDA-approved. So you have d- like a lateral flow assay, which looks like a pregnancy test, where you have a little bit of a small container with two bands, one for control and one for the positive or negative. And, you have complement fixation, you have ELISAs. You have different types of serology that could be done from the blood, and it is the most commonly available test for providers to do. Unfortunately, it's not super regulated. None of that is FDA-approved. You could do it. You could send it. It will take some time. The problem we have is when you have an uncommon disease, sometimes false positive is even more common than true positive, and that becomes a major challenge for somebody like you or me, where when we see the patient and you test them and they come back positive, does he have it or no? I... It's hard, and you ask yourself,"Should I have done the test or not?" It becomes complex. PCR is done early would be very highly predictive. Late in the game, sometimes it doesn't help you that much.

Mohamed 18:13

Okay. So let's just backtrack a little bit'cause you talked a lot about serology, which I have a lot of questions about, which you probably addressed most of them. But even before then, let's say, a-again, a lot of my audience are pre-hospital audience, nurses, PAs, nurse practitioners, and also physicians. And whenever they see these people initially, let's say there is a high-risk exposure, came from an endemic region. They have these kind of, prodromal symptoms, and there's a concern for hantavirus. Before the serology Is there a sensitive test?'Cause I heard a lot about thrombocytopenia. How sensitive is thrombocytopenia in these patients for hantavirus, obviously? How sensitive it is for hantavirus.

Dr. Yassin 18:56

So if you are saying 70% of the hantavirus patients early on will have thrombocy- thrombocytopenia, I think you're correct. But if you tell me how many people will come with thrombocytopenia that have hantavirus, then probably you're more likely to be incorrect. So it depends on the... Yeah, so I'm saying you have a lot of symptoms, the right epidemiology, and this will make you feel like,"Yeah, maybe that's the case." flu could cause thrombocytopenia. Many of the viral illness could cause thrombocytopenia.

Mohamed 19:29

Leukopenia also with COVID too. We saw COVID

Dr. Yassin 19:31

Yeah. Yeah. Anaplasma, ehrlichia, a lot of the tick-borne illnesses could do that. So really, it's not very specific, unfortunately. And if you really have a suspicion, I think you gotta order the serology if you ask me.

Mohamed 19:45

And what about hemoconcentration, increased hemoglobin, increased hematocrits? What about leukocytosis? what about the, increased-- the presence of blasts in the blood smear? do they count at all? m- or do we actually maybe ignore them or do they mean something in this setting?

Dr. Yassin 20:04

Of course, w-we are clinicians, so we... You use everything to make your case, and you look for every little detail to try to say,"I think that's the case." So when you're talking about the blast that you see are very helpful for sure. You're talking the number for the diagnostic criteria, ten percent or more. Sounds to me like you're hitting a more important target here. That may be something to look for. But generally speaking, hemoconcentration happens from so many reasons. So many reasons. And, I would say most of these lab results are helpful if you have a high index of suspicion. If you don't have high index of suspicion, none of that is pathognomonic. None.

Mohamed 20:47

Yeah. That makes a lot of sense. that's like the art of medicine, right? What is your pretest probability for

Dr. Yassin 20:52

Yes.

Mohamed 20:53

in that setting? This is why we have to build the overall picture of the patient in front of us. Now, let me ask you this. Let's say if there's a concern for hantavirus exposure, what is the recommendation for isolation in terms of what is the recommendation for, masking and things like that? Is a simple mask enough? N95? Yep

Dr. Yassin 21:16

Yeah. Theoretically speaking, when we're talking, let's say you have one case and you saw him in your clinic, not even in the hospital, and the patient looks great, and he has a lot of rodents, and he deal with them, and you think that's the case. I'm not sure how much isolation is needed. But if you're facing something and you're not sure what is going on, most of us as, healthcare epidemiologist or doing infection control in healthcare facilities, we recommend the maximum precautions. That includes probably contact and airborne. So you talk about N95 goggles. There, there's a lot of discussion about that, that most of the people say,"Just cover your eyes. That's important." You talk about aerosol generating. You're doing a bronchoscopy, like what you do for patients. you gotta be very careful with the aerosol in those patients So I would say healthcare, acute healthcare hospitals have a different code than the community or looking at the cases. Remember, back to the same point,

Mohamed 22:18

Mhm. Mhm.

Dr. Yassin 22:19

Person-to-person transmission is not the main way of transmitting that disease. But if you have a doubt and you don't know what you're dealing with, I think use the maximum precautions. And in my mind, I call it universal precautions rather than a specific precaution for that disease. Just protect yourself, protect the nurses working with you, protect the staff, protect the other patients. I think that makes a lot of sense to me. But, I don't think this is a recommendation because of the way this virus transmits. It just because s-- yeah, you could be dealing with different strain. This is a sick patient. You may be doing aerosol-generating procedures. You gotta be careful when you have critically ill patients, and I would say probably maximum precaution. Goggles, N95 mask or respirator, and I would say even contact like a gown and gloves when you're dealing with that patient and his secretions. But I would say that's mostly because of the worry that there may be something else is going on.

Mohamed 23:19

And what is really the main, method of transmission? Is it aerosolized? Are we sure about that?

Dr. Yassin 23:25

Your aerosol from the mouse or the rodent to the human.

Mohamed 23:29

Both from the rodent to the human. What about human to human in the case of the

Dr. Yassin 23:34

as I said, yeah, it definitely does happen. It definitely does happen. And I would say aerosolization would be a very effective way, unfortunately, of causing that transmission. remember when we talked about human to human, we said close contact. So imagine two people, you put them next to each other and breathing right there, or you do a nebulization or intubation or something, that person could definitely transmit infection to the other person too. So if you're the emergency room physician seeing a patient that's suspected to do that and you're gonna intubate, or your respiratory therapist who's gonna introduce some suction or do something for that patient, I would say do maximum precautions when you're dealing with this kind of thing because that's the highest risk for sure. A casual contact from the room saying,"Hey, do you have a problem? You doing okay?" I'm not sure a hundred percent how much you need for that. But the close contact, the aerosolization will be probably the highest risk

Mohamed 24:32

Let's talk a little bit about cardiopulmonary syndrome. Let's say now we have a patient in that disease process, that's their presentation. Obviously, they're gonna present altered, maybe hypotensive signs of multi-organ injury or dysfunction, maybe concern for sepsis as well. Maybe the clinician would throw some antibiotics on them. But cardiopulmonary syndrome, you mentioned an important point, which is avoiding excessive IV fluid. So jump directly to, hemodynamic stability with vasopressor.

Dr. Yassin 25:03

Correct.

Mohamed 25:04

And, let's say we have now an undifferentiated cardiopulmonary syndrome. we see some thrombocytopenia, hemoconcentration. How soon do we need to jump into more aggressive methods, dialysis, ECMO, intubation, things like that?

Dr. Yassin 25:24

Yeah. So this probably will be in collaboration. I'm not sure if I will be the only one who's making that decision, but you're hitting a very important point. You're telling me ECMO will be a life-saving for some of those patients that needs that done. Should I wait? I don't think we should wait. I think that should be done as soon as you suspect that's the case, or you really think that's the case, and that patient is in need for that. I think the referral to ECMO would be the best thing you could do for that patient to save his or her life for sure. I don't think we should wait.

Mohamed 25:58

To be clear, honestly, like when I was reading the literature, once they reach that point of cardiopulmonary syndrome, the mortality is very high. It's anywhere between thirty-three percent to forty-five percent. So up to one in two patients can die from this. and even like the recommendation is not even to intubate them, try to cannulate them first, send them to a center that has ECMO capability, and then start them on VA ECMO, and then intubate them and do all those things. and the prognosis is very good. up to eighty percent of them in a, well-experienced ECMO center actually survive this. But I think the problem lies with the delay in diagnosis, if that makes sense. So this is once they get there, we do what we need to do aggressively, intubate them, hemodialysis, do this, do that, and then we delay the process of initiating ECMO. So it's very important for us to recognize that once they hit the cardiopulmonary syndrome, they already have high mortality risk, so we have to jump quickly into VA ECMO, which to me now, As a clinician, I wanna know what is a prognostic feature. is the severity of thrombocytopenia tells me that they're likely gonna die? Is it the level of hemoconcentration? Just a way of prognosticating these patients, Like, how aggressive should I be in moving them to an ECMO center from, let's say, a rural system in, in the middle of nowhere, Pennsylvania, in the middle of nowhere in a country? Like, how aggressive should I be? That is the challenge that I have when reading about this.

Dr. Yassin 27:35

I think if you ask me, and that's my personal opinion, I would be very aggressive. I wouldn't wait. I would just seek referral for that patient to go for ECMO. And this is also tricky because for example, the University of Pittsburgh, the ECMO unit, they wanted nobody to cannulate before they get the patient there. They used to accept cannulating anywhere and send the patient. Now their infection rate becomes very high, so they do not wanna do that. They want assess the patient and cannulate in their unit there. So it becomes different styles for different units. And in my mind, if I think what you're saying that there is a cardiopulmonary disease with possible need for ECMO, I'm gonna be on the phone with the nearest ECMO unit. What do you want me to do? Cannulate here or send him to you and you will do that? I don't think we should wait for a day or two and try and see how it goes I don't think that would be the right way, especially if I have a very high index of suspicion of hantavirus or confirmed case. Either way, I will have a very aggressive, very early intervention.

Mohamed 28:43

That makes a lot of sense to me. honestly, if I can prove somehow that this is indeed a hantavirus, infection with severe disease, I'm gonna be very aggressive. Which comes down now to testing, and I know you alluded to when it comes to testing, PCR is gold standard or is it ELISA?

Dr. Yassin 28:59

so when we say gold standard as a academic language, we mean the best way to diagnose a test or the most confirmatory test. But in general, as clinician, you and I have sensitivity, specificity, true positive, false positive. That's how we operate. So when you do a test and you have a very high probability, you really wanna confirm that. So you want the test to add to your clinical suspicion and vice versa. When you don't think it is the case, you want the test to help you to almost rule it out totally. In my mind, most of the people use serology as the first step. I think confirmation with a PCR would be a good idea. The problem with the PCR or the serology is there's so many different types, and there's no standard FDA approval for that. So that means different laboratories could have different primers, different, areas that they actually look into the virus. most of the serology based on the nucleocapsid, which is almost similar to like COVID antibodies, as an example, and that gives you an idea that there is a human infection, and that's when you get the part of the virus in the blood or something like that. yeah, it's hard for me to comment on sensitivity, specificity for PCR as compared to the serology because we don't do a lot of it, and we don't have a lot of even large surveillance data. We have small clusters, and I would say PCR would be more sensitive, if you ask me. most of those cases, if I encounter a case here in Pittsburgh today or tomorrow, I'm gonna be sending it to the local, notifying the Allegheny Health Department, probably the state, and make sure that another specimen will be sent to the CDC for further testing to confirm what we're looking at for sure. I think that's the way I would do it. So not only sending to the local lab for asking for serology, I'm gonna make sure I have more than one specimen sent to a referral lab as well as local lab. I get the results quick. And I get a confirmation from a bigger nationwide level testing as well.

Mohamed 31:10

That's an important point. So this is a reportable disease. This is we have to

Dr. Yassin 31:14

Of course.

Mohamed 31:15

to the local authorities. So we talked a little bit about, again, presentation. they can be vague initially, and then they can proceed with severe presentation of the disease process. So the management is mostly supportive, right? Supporting their hemodynamics, being cautious with IV fluid in these patients with non-cardiogenic pulmonary edema, being ag-aggressive initially, advocating for ECMO, early for these patients. Now, besides supportive management, is there a specific treatment?

Dr. Yassin 31:50

I'm sure you're gonna ask me about ribavirin and other antiviral too.

Mohamed 31:54

Right

Dr. Yassin 31:55

I actually don't think any of that work, and we have at least two studies for ribavirin. So when you have a, an, I would say, not common disease, and you're trying to say,"I have two case reports reported five hundred years ago that ribavirin worked or zinc helped that patient," I would call it anecdote more than an actual study. We have two studies done on the ribavirin. Neither of those two studies show a benefit. There's no increased harm, but there's really no benefit. And, I think the answer to that is it's too late. Because remember, they have a long incubation period, and if you do not intervene very early on when the patient is sick, when he's coming to you symptomatic, I bet none of these antiviral work. But our data is limited, to be very precise, and I'm not aware of any specific antiviral that we can use for that scenario. Should we test more antiviral and see if they work in vitro and try? I don't see why not. I don't see why not. But you're asking, does this medicine work? The answer is, I'm not aware of any medicine that reliably works in that case. Supportive management.

Mohamed 33:12

Yeah. S-so supportive management, but no monoclonal antibodies, no antivirals, none of that work, right? Currently, as of our current knowledge, there is no proven therapy against the virus.

Dr. Yassin 33:25

That is correct. B-but just a comment on the monoclonal antibodies, actually a very interesting point you're raising. so compassionate use, for somebody who's in, in very bad shape and u- like University of Pittsburgh, we have a very advanced lab For monoclonal antibodies, and they can tailor and make for different viruses and different disorders. They can do a lot of stuff very quickly. but this will not be a proven medication, but a more of a compassionate use like that patient... As a physician, you discuss with the family. We don't have any medicine that I can provide with certainty that could work. All we have is supportive care. I may have a experimental medicine. Are you willing to go for that? I can't give you an idea how likely this would work, and I can't say 100% if it's safe or not. So compassionate use may not be a terrible idea for a lethal disease like this, but there's no proven benefit for either monoclonal or antiviral, as you correctly said.

Mohamed 34:27

Let's say you are able to catch it early. These people from the cruise ship, now they're being quarantined, and I'm sure they're being tested, right? Ser- serology testing, PCR testing All the stuff, and they find that one of them is infected, but they have no symptoms. So asymptomatic infection. Is there anything actually working? do they need antiviral therapy? anything else right now, even before the symptoms start?

Dr. Yassin 34:51

I'm not aware of anything we can do at this moment other than observation and, quarantine. Just, yeah. Unfortunately. Unfortunately.

Mohamed 34:58

timeline? are they gonna be quaran- like you said, quarantined for seven weeks, two or three weeks?

Dr. Yassin 35:04

Yeah. So we said the incubation period is typically two to three weeks. That's where the majority of the cases would occur. But the, in this last outbreak in the cruise ship, the WHO recommended forty-five days of quarantine, so almost close to what? Six, six to seven weeks. That's what they recommended. I think it's reasonable to be very careful with that. You have a lot of exposed people. You don't wanna spread globally something. So I think, this is a consideration for this particular scenario. But generally speaking, if you have an isolated case, we're talking two to three weeks.

Mohamed 35:42

And lastly, is there a current vaccine that exists against the hantavirus strains?

Dr. Yassin 35:46

This is in my wish list, but nothing exists.

Mohamed 35:50

Do you know even why that is not the case? Is it a money issue? Is it a, I don't know. Is it-- Do you have-- Is there a specific reason for that?

Dr. Yassin 35:57

I don't think there is, but there was interest before COVID, and I was part of that discussion honestly with the CDC about initiating campaign to try to get hantavirus vaccination available and other viruses too. However, when the COVID hits- Almost all the efforts went this way. so you're asking me, it's a single RNA virus. Would you, consider having some sort of protein, small or medium or large protein from those three in the virus as a core for the vaccination? I can't say it's impossible. And would you s- make this for high-risk population that deal with rodents, plumbers, sewage people, other people that do some work with that, that they can't... people who do garbage disposal, stuff like that. You, y- you could argue that way. Is this gonna be financially, possible that some company would take that work, spend all this money to find that vaccine? I can't answer to that question. It's a tough question for me, but based on what I have, I would say I'm not aware of a vaccine available at this moment.

Mohamed 37:10

Dr. Yassin this has been a great discussion, and for the sake of time, I think we covered the main points of this public health emergency. So one thing, based on the massive surge of information on social media from various resources, as a clinician, a scientist, and infectious disease specialist, what advice and words of wisdom do you have, for the general public.

Dr. Yassin 37:38

If I have one message to focus on, I would say remember that rodents and humans should not be together in a safe space. So cleanliness, making sure that if you own a restaurant or you eat in a restaurant, make sure it's clean. If you have a shed that you clean, make sure it's clean. If you have an attic or basement, make sure it's clean. Cleanliness is extremely important to avoid such a thing. So I can't say that the cruise ship had mice or rats on it. I don't know that information. But I'm saying we should not be coexisting together in a place because that could put us at a risk for so many diseases. hantavirus is just one of them, but there's tons of other vi- viruses, bacteria, worms. There's so many protozoa, so many disorders that can happen to us from these rodents. So we gotta keep things clean. For sure, that's how I see it as simple. I... That would be one, number one advice. Number two is the main transmission of this disease is not human to human. We have to be very clear. It's rodent to human. So if you avoid rodents, you're really ninety percent out of trouble

Mohamed 38:46

That's why it's very important to emphasize awareness over panic, science over speculation, and preparedness over fear. This is all of these things that we need to ensure that the general public get the right information from the right sources. So thank you so much, Dr. Yassin for being such a, useful asset to this, podcast, and I appreciate you for being here, and I appreciate you sharing all these insights about the hantavirus. So everybody else, please stay safe, and thank you so much for listening.

Dr. Yassin 39:16

Thank