1993 Four Corners hantavirus outbreak

1993 disease outbreak May 2026 February 2025 File:Four Corners Monument (1).jpg A photograph of the Four Corners Monument, at the spot where the borders of Arizona, Colorado, New Mexico, and Utah meet each other The Four Corners Monument, at the spot where the borders of Arizona, Colorado, New Mexico, and Utah meet Hantavirus pulmonary syndrome Sin Nombre virus Four Corners region, United States 1993 Western deer mouse 33 in Four Corners states;48 nationwide 16 in Four Corners states;21 nationwide 17 in Four Corners states;27 nationwide 52% in Four Corners states;56% nationwide An outbreak of hantavirus disease occurred in 1993 in the United States, primarily in the Four Corners region of Arizona, Colorado, and New Mexico. Before 1993, hantaviruses that cause disease in humans, native to rodents, were known to spread mainly in Asia and Europe and to cause hemorrhagic fever with renal syndrome. The outbreak in 1993 led to the discovery of hantaviruses from the Western Hemisphere that could cause disease and revealed the existence of a second disease caused by them: hantavirus pulmonary syndrome (HPS). In the Four Corners states, 17 of the 33 HPS cases in 1993 resulted in death, a 52% case fatality rate. Nationwide that year, 27 of the 48 HPS cases resulted in death, a 56% case fatality rate. The earliest confirmed cases of HPS in 1993 occurred in March, but the outbreak was not discovered until May when a young Navajo couple died within days of each other due to sudden respiratory failure. Investigators quickly found other people with the same symptoms as the couple. Further investigation discovered a new hantavirus, Sin Nombre virus (SNV), as the cause and identified the western deer mouse as its natural reservoir. Public health officials gave advice on how to prevent infection, and the antiviral drug ribavirin was tested on suspected cases. While the first cases to be identified were in the Four Corners region, more cases were identified outside of the area as the year went on but not in the Four Corners state Utah. Before research in 1993 showed that SNV was not spread between people, there was widespread fear that HPS was contagious. Consequently, Native Americans of the Four Corners region, especially the Navajo, experienced discrimination and racism during theoutbreak. The 1991–1992 El Niño indirectly caused the outbreak by producing a warmer-than-usual 1992–1993 winter and increased rainfall in the spring of 1993 in the Four Corners region. This increased the amount of vegetation available for rodents for food and shelter, which led to a significant increase in their numbers. The increased population density of rodents allowed SNV to spread more easily, and with a much larger population, interactions with people were more likely to occur. Further research has uncovered HPS cases before the outbreak as far back as 1959. Since the outbreak, hantaviruses that cause HPS have been identified throughout the Americas. In North America, SNV is the most common cause of thedisease. HPS infections are rare, but they have a case fatality rate ranging from 12% to 45%, varying by virus. Treatment is supportive, and prevention is based on minimizing contact with rodents. Background thumb|alt=An image showing where the Four Corners region is located|The Four Corners states are highlighted and include a circle to indicate the location of the Four Corners. The Four Corners refers to the region surrounding the four-state border between southwestern Colorado, northwestern New Mexico, northeastern Arizona, and southeastern Utah.Colorado Plateaus Province https://www.nps.gov/articles/coloradoplateaus.htm National Park Service live https://web.archive.org/web/20250222130505/https://www.nps.gov/articles/coloradoplateaus.htm February 22, 2025 March 30, 2025Price Clancy Graham Kersten 2014 sec. "Abstract" Most of the area is divided into reservations for Native American nations and tribes, namely the Navajo Nation, Hopi Reservation, Ute Mountain Ute Tribe, Southern Ute Indian Reservation, Zuni Indian Reservation, and Jicarilla Apache Nation.Robbins MW May 18, 1985 Four Corners https://www.washingtonpost.com/archive/lifestyle/travel/1985/05/19/four-corners/0aaeb9ee-c10d-454b-8143-d485d1c297d7/ The Washington Post https://web.archive.org/web/20250330213152/https://www.washingtonpost.com/archive/lifestyle/travel/1985/05/19/four-corners/0aaeb9ee-c10d-454b-8143-d485d1c297d7/ March 30, 2025 March 30, 2025 Thissparsely populated areaHarper Meyer 1999 42 is part of the Colorado Plateau, a desert region with mountains, canyons, and sedimentary rock formations.Klauk E May 22, 2006 Physiography of the Navajo Nation https://serc.carleton.edu/research_education/nativelands/navajo/physiography.html Science Education Resource Center at Carleton College live https://web.archive.org/web/20240604150521/https://serc.carleton.edu/research_education/nativelands/navajo/physiography.html June 4, 2024 January 4, 2025 Hantaviruses are a group of viruses that constitute the taxonomic family Hantaviridae. Hantaviruses that cause disease in humans are native to rodents and assigned to the genus Orthohantavirus. Each species of hantavirus is usually transmitted by one rodent species.Chen Gong Wang Sun 2023 sec. "Taxonomy and Distribution of Hantaviruses" Before the 1993 Four Corners outbreak, Old World hantaviruses were known to cause hemorrhagic fever with renal syndrome (HFRS) and nephropathia epidemica, a milder form of HFRS, in Asia and Europe.Kuhn Schmaljohn 2023 sec. "The Beginning of the Hantavirology"Avšič-Županc Saksida Korva 2019 e6 Before this outbreak, New World hantaviruses were not known to infect or cause illness in humans.Kuhn Schmaljohn 2023 sec. "A New Disease"Van Hook 2018 2058 Course of outbreak thumb|alt=A stacked bar chart showing HPS cases (lived and died) in the US in 1993 by month|HPS frequency in the US in 1993 by monthJune 26, 2024 Reported Cases of Hantavirus Disease https://www.cdc.gov/hantavirus/data-research/cases/index.html Centers for Disease Control and Prevention January 4, 2025 thumb|alt=A map showing HPS cases in the US in 1993 by state and territory|HPS frequency in the US in 1993 by state and territory After HPS was discovered in May 1993,Grady D May 21, 2019 December 1993 Death at the Corners https://www.discovermagazine.com/health/death-at-the-corners Discover live https://web.archive.org/web/20240912091314/https://www.discovermagazine.com/health/death-at-the-corners September 12, 2024 January 4, 2025 the outbreak was confirmed to have started earlier, in March.CDC MMWR January 28, 1994 46 A dozen more cases were reported, mostly among the Navajo, in the weeks after the discovery. The outbreak continued to worsen through June and peaked in July before a sharp decline in August.CDC MMWR January 28, 1994 46 HPS was first reported outside the Four Corners in Texas, in June.CDC MMWR July 9, 1993 517–518CDC MMWR July 30, 1993 570 By mid-August, 23 hantavirus infections had been confirmed in the Four Corners region. In the Southwest, 20 of the 30 confirmed cases resulted in death, a 67% case fatality rate.CDC MMWR August 13, 1993 612 As the year went on, an increasing number of cases were identified outside the Four Corners region.CDC MMWR August 13, 1993 612–614 CDC MMWR September 17, 1993 707 CDC MMWR October 29, 1993 816 By October, 60 cases of hantaviral disease had been reported nationwide, about half in the Four Corners region. Thirty-nine of these cases were confirmed by laboratory testing, 25 of which led to death.CDC MMWR October 8, 1993 770 From August to December, new reports of HPS were relatively low, except for a spike in October.CDC MMWR January 28, 1994 46 By the end of the year, 48 cases had been confirmed nationwide, 27 of which resulted in death. This 56% case fatality rate was similar across age, sex, and race,CDC MMWR January 28, 1994 45 and it declined as physicians learned to quickly recognize HPS, identify less severe cases, and effectively treat HPS.Harper Meyer 1999 92 Most of the infected were male, and, in the Four Corners region, all of the infected either lived in or visited rural areas before falling ill. Of the 33 cases to occur in 1993 in Arizona, Colorado, and New Mexico, 26 occurred during the height of the outbreak from April to July, and 17 died, a 52% case fatality rate. The only Four Corners state where no HPS was identified in 1993 was Utah.CDC MMWR January 28, 1994 45–46 Outbreak investigation Discovery On May 11, 1993, a 19-year-old Navajo man, a competitive long-distance runner, visited the hospital in Crownpoint, New Mexico,Harper Meyer 1999 7 for fever, muscle pain, chills, headache, and malaise. He was given an antibiotic, a drug for influenza A, and a painkiller and discharged from the hospital. He returned two days later due to persistent symptoms, vomiting, and diarrhea and was discharged with no change in treatment.Pottinger 2005 40 On the morning of May 14, he was traveling with his family from Crownpoint to Gallup, New Mexico, when he became severely short of breath. They stopped their car in Thoreau, New Mexico, about 30 miles (42km) east of Gallup, and contacted emergency services. By the time help arrived, he had collapsed due to respiratory failure. An ambulance crew performed CPR as he was taken to the Gallup Indian Medical Center, where he was found to have fluid buildup in his lungs (pulmonary edema). Despite efforts to resuscitate him, he died. The death of the young man due to sudden respiratory failure confused medical staff.Harper Meyer 1999 7Van Hook 2018 2056 thumb|left|alt=A photograph of buildings in downtown Gallup, New Mexico|Gallup, New Mexico, where the outbreak was first noticed by investigators Because the man's death was highly unusual, it was required by law to be reported to the New Mexico Office of the Medical Investigator (OMI) inAlbuquerque, where autopsies are conducted. The deputy medical investigator in Gallup, Richard Malone, was called in to investigate hisdeath. Malone had investigated a similar death of a 30-year-old Navajo woman a few weeks earlier, in April, at the same medical facility inGallup. The woman's death, attributed to pulmonary edema, was examined post mortem by University of New Mexico (UNM) pathologist Patricia McFeeley, who worked with the New Mexico OMI. The woman's lungs were filled with blood plasma and more than twice as heavy as usual. Test results were negative for known infections that could have caused her death. Malone contacted McFeeley on the day of the man's death to discuss the similarities between the two cases, and she agreed to perform an autopsy on the deceased man once permission was obtained from his family.Van Hook 2018 2056 Malone spoke to the parents of the deceased man and hoped to receive information about what could have caused his death. They told Malone that their son collapsed while they were on their way to the funeral of his fiancée. She had died five days earlier, on May 9, at the hospital in CrownpointHarper Meyer 1999 6–7 with the same symptoms as her fiancé. Since Crownpoint is on the Navajo reservation, the medical facility there was not required to report her death to the New Mexico OMI and did not do so.Van Hook 2018 2056–2057 Furthermore, due to her history of asthma, her death was not considered alarming at first.Sternberg S June 14, 1994 Tracking a Mysterious Killer Virus in the Southwest https://www.washingtonpost.com/archive/lifestyle/wellness/1994/06/14/tracking-a-mysterious-killer-virus-in-the-southwest/5e074ccd-7d88-41c0-9dc4-c0edcc1cd16e/ The Washington Post https://web.archive.org/web/20170710232434/https://www.washingtonpost.com/archive/lifestyle/wellness/1994/06/14/tracking-a-mysterious-killer-virus-in-the-southwest/5e074ccd-7d88-41c0-9dc4-c0edcc1cd16e July 10, 2017 March 7, 2025 live After updating McFeeley on the situation, Malone convinced the families of the deceased to have the couple's bodies examined in autopsy. Later that day, McFeeley reported a possible outbreak of an unknown and deadly respiratory illness to the state health department in Santa Fe and prepared for autopsy. The autopsies of the couple showed only severe pulmonary edema with no explanation for the cause ofillness.Van Hook 2018 2057 Expanded scope thumb|left|alt=A photograph of the Centers for Disease Control and Prevention in Atlanta, Georgia|Scientists from the CDC helped identify the cause of the outbreak. Pictured is the CDC's headquarters in Atlanta, Georgia. Malone then contacted Bruce Tempest, the medical director of Gallup Indian Medical Center. Tempest recalled having been involved in at least two discussions with physicians who had cared for young, previously healthy tribal members who suddenly died from an unknown respiratory illness. Malone and Tempest agreed that the situation required further action, so they searched for more cases.Van Hook 2018 2057 Tempest was aware of the three recent cases in New Mexico as well as one from the previous November in Arizona. Health officials in Arizona informed him of another recent case, so on May 17, Malone and Tempest notified the New Mexico Department of Health of their concerns.Van Hook 2018 2057 State officials notified the Centers for Disease Control and Prevention (CDC) on May 18 and began an investigation with the Indian Health Service (IHS) and the Navajo Nation's health department. They examined the homes of the deceased and interviewed their families and the physicians who had cared for them.Harper Meyer 1999 10–11 On May 24, New Mexico state officials sent a letter to clinicians in the Four Corners states that described the illness and situation and asked for any similar cases to be reported to them immediately, which identified several potential cases.Van Hook 2018 2057 After learning of the situation, the press reported on May 27Harper Meyer 1999 14 that an unknown disease was killing young tribal members in the Four Corners, which caused great anxiety in the public. Navajo and Hopi people were ostracized from the rest of society, and politicians faced pressure to respond to the situation.Van Hook 2018 2057 On the same day,Harper Meyer 1999 21 New Mexico state officials contacted the CDC and asked for assistance. On May 28, a team of investigators was created and Jay Butler, an epidemiologist at the CDC's Epidemic Intelligence Service, was made the leader of the team.Van Hook 2018 2057Harper Meyer 1999 22 Less than a day later, the group arrived at Albuquerque and was transported to the University of New Mexico. There, they were joined by members of the UNM medical faculty, IHS physicians, infectious disease and toxicology experts, physicians who had treated the deceased, and various state and national health officials.Van Hook 2018 2057 Robert Breiman, a respiratory disease expert, was selected to lead the field investigation, while C. J. Peters, the head of the CDC's Special Pathogens Branch, was put in charge of the laboratory work being done at the CDC in Atlanta, Georgia.Harper Meyer 1999 21–22 In a meeting that took place from May 29 to May 31, the task force agreed to evaluate any person in the area from January 1, 1993, onward who had radiological imaging that showed evidence of unexplained excess substances in both lungs (bilateral infiltrates) with low levels of oxygen in the blood (hypoxemia) as well as any death accompanied with unexplained pulmonary edema. Thegroup received clinical information about more than 30 suspected cases and considered various causes of illness. Plague, tularemia, and anthrax, among other diseases, were eliminated from consideration due to lack of evidence. The team believed the outbreak to be caused by either a new, aggressive form of influenza, an environmental toxin, or a previously unrecognized pathogen.Van Hook 2018 2057 Hantavirus suspected thumb|alt=A photograph of a deer mouse|Authorities captured rodents to identify the natural reservoir of the virus causing the outbreak. The western deer mouse was the most commonly captured species and was later confirmed to host the virus.note Many sources, including those from 1993, identify the natural reservoir of Sin Nombre virus as the species Peromyscus maniculatus. In fact, the natural reservoir of the virus is the species Peromyscus sonoriensis. The reason for this discrepancy is because the two species were previously classified as one, both under the scientific name Peromyscus maniculatus. This species was reorganized in the late 2010s and split into multiple species, including P.maniculatus and P.sonoriensis. The "old" P.maniculatus had a range extending across most of North America, whereas the "new" P.maniculatus is limited to southeastern Canada and the northeastern parts of the US east of the Mississippi River. P.sonoriensis, on the other hand, is found in most of the US west of the Mississippi River, including in the Four Corners region, and in most of southwestern Canada, which corresponds to where Sin Nombre virus infections usually occur.Greenbaum Honeycutt Chirhart 2019 563Whitmer Whitesell Mobley Talundzic 2024 sec. "Geographic and temporal distribution of STLT-reported acute hantaviral disease"Finkbeiner Khatib Upham Sterner 2025 sec. "Introduction" The investigative team started reviewing medical records on June 1 and obtained tissue samples from suspected cases. Meanwhile, epidemiologists interviewed patient and control families and inspected their homes and workplaces.Van Hook 2018 2057 After testing at a local laboratory continually yielded negative results, samples were sent to the CDC in Atlanta for immediate analysis. By June 4, scientists at the CDC's Special Pathogens Branch had tested IgM antibodies from nine people with 25 different virus samples. Antibodies from every person reacted to three hantavirus species and none of the other viruses: Hantaan virus, Puumala virus, and Seoul virus, each of which can cause HFRS. Theantibody samples were then shown to be reactive to Prospect Hill virus, a hantavirus discovered in eastern meadow voles in Maryland that had never been associated with human disease or isolated from human tissue.Van Hook 2018 2057–2058Harper Meyer 1999 30–31, 126 Several investigators had experience with and knowledge of HFRS.Van Hook 2018 2058 A distinctive feature of the disease is a significant increase in the vascular permeability of capillary endothelial cells, mainly in the kidneys,Van Hook 2018 2058Koehler Di Cristanziano Späth Hoyer-Allo 2022 1237 which causes massive loss of intravascular fluid into the space behind the lining of the abdominal cavity.Van Hook 2018 2058Bui-Mansfield Cressler 2011 1332 The loss of intravascular fluid causes the density of blood cells in blood to increase, a condition called hemoconcentration.Van Hook 2018 2058Johnson 2001 10 High levels of hemoconcentration were observed in several potential cases in the ongoing outbreak and, combined with the CDC's findingsVan Hook 2018 2058 and the discovery of mouse feces at a home of the deceased,Donovan B May 17–18, 2008 Year of Fear: Medicine Men Knew Cause of Hantavirus http://www.gallupindependent.com/2008/may/051708hantavirus.html The Gallup Independent https://web.archive.org/web/20100317063542/http://www.gallupindependent.com/2008/may/051708hantavirus.html March 17, 2010 March 7, 2025 live a hantavirus was suspected of causing the outbreak.Van Hook 2018 2058 Before the outbreak, hantaviruses identified in the Western Hemisphere were only known to infect rodents, with no instances of human disease caused by them observed.Van Hook 2018 2058note Seoul virus, a pathogenic Old World hantavirus, was detected in the Western Hemisphere before 1993. As such, the 1993 outbreak represents the discovery of pathogenic New World hantaviruses in the Western Hemisphere.Clement LeDuc Lloyd Reynes 2019 sec. "Prelude" There were also no known hemorrhagic fevers native to North America,note Apart from hantaviral disease, the only other hemorrhagic fever native to North America is caused by Whitewater Arroyo virus,Gonzalez Souris Valdivia-Granda 2018 sec. "Preamble" which was first described in 1996Fulhorst Bowen Ksiazek Rollin 1996 sec. "Abstract" and connected to human disease in 1999–2000.CDC MMWR August 11, 2000 709 Dengue virus, the cause of Dengue fever, exists in southern North America, but it is not native and was introduced into the Americas in early modern times.Brathwaite Dick San Martín Montoya del Diego 2012 sec. "Introduction of Dengue in the Americas (1600–1946)"Salles da Encarnação Sá-Guimarães de Alvarenga Guimarães-Ribeiro 2018 sec. "A brief history of dengue in the Americas" and none of the infected had traveled abroad or come into contact with foreigners before falling ill. Furthermore, unlike with HFRS, the disease had little kidney involvement; in all instances, the main organs affected were the lungs. Nonetheless, an unknown hantavirus that specifically infected pulmonary capillary endothelial cells was suspected by some investigators.Van Hook 2018 2058 Acting on the information gathered so far, the CDC dispatched a rodent trapping team to New Mexico, which proceeded to capture around 1,700 rodents from June 7 to mid-August at patient and control sites. The most commonly captured species was the western deer mouse.Van Hook 2018 2058Tracking a Mystery Disease: The Detailed Story of Hantavirus Pulmonary Syndrome (HPS) https://www.cdc.gov/hantavirus/outbreaks/history.html Centers for Disease Control and Prevention https://web.archive.org/web/20231221050817/https://www.cdc.gov/hantavirus/outbreaks/history.html December 21, 2023 February 20, 2025 live New viral disease thumb|alt=Transmission electron micrograph of Sin Nombre virus|Transmission electron micrograph of Sin Nombre virus, the virus responsible for the outbreak. The spherical particles are extracellular virus bodies (virions). At the same time as the rodent trapping operation, scientists at the CDC's Special Pathogens Branch worked to identify the virus. On June 10, reverse transcription polymerase chain reaction (RT-PCR) was used to obtain a DNA sequence 139 base pairs in length from one segment of the virus's genome from samples taken from two people who had died from the disease.Van Hook 2018 2058 Additionally, hantaviral antigens were identified in samples of tissues, such as the endothelium of the pulmonary capillary bed, by the CDC's Viral Pathology Laboratory. On June 16, the same team identified an identical viral base pair sequence and hantavirus antibodies in western deer mice captured on site, which conclusively identified the virus and its natural reservoir.Van Hook 2018 2058 By late June, testing had shown that about 30% of trapped western deer mice and smaller percentages of rodents of other species had been infected by the virus.CDC MMWR June 25, 1993 478 Late that summer,Stumpff 2010 9 researchers confirmed that the virus does not spread between people.Krüger Schönrich Klempa 2011 687 The virus was first cultured in November 1993 by teams at the CDC, which used tissue from a deer mouse trapped near the home of an infected person in New Mexico, and the US Army Medical Research Institute of Infectious Diseases (USAMRIID) at Fort Detrick in Frederick, Maryland,Van Hook 2018 2058 which used samples taken from a mouse trapped in California and tissue of an infected person in New Mexico.Harper Meyer 1999 92–93 Initially, the virus was named Four Corners virus before being rejected because of the negative association with the region.Kuhn Schmaljohn 2023 sec. "A New Disease"Pottinger 2005 37Harper Meyer 1999 95 The CDC and USAMRIID then, inJanuary 1994,Garrett L September 9, 1995 The War Between Man and Microbe https://www.the-independent.com/arts-entertainment/the-war-between-man-and-microbe-5649830.html The Independent live https://web.archive.org/web/20250813234632/https://www.the-independent.com/arts-entertainment/the-war-between-man-and-microbe-5649830.html August 13, 2025 August 13, 2025 gave the virus the name Muerto Canyon virus after a location near where the disease was first observed,Van Hook 2018 2058Harper Meyer 1999 95 as it is customary to name hantaviruses after where they are discovered.CDC MMWR January 28, 1994 47Mariappan Pratheesh Shanmugam Rao 2021 sec. "Hantaviridae: Molecular pathogensis of Hantavirus" The Navajo, however, strongly opposed any further association with the virus because of the racial discrimination that it had triggered against them.Van Hook 2018 2058 Moreover, the name was problematic given that Muerto Canyon was named after the massacre of 115 Navajo by Spanish troops in 1805,Harper Meyer 1999 96Arizona: Canyon de Chelly National Monument https://www.nps.gov/articles/dechelly.htm National Park Service live https://web.archive.org/web/20250418073208/https://www.nps.gov/articles/dechelly.htm April 18, 2025 August 13, 2025 so the Navajo Nation Council unanimously voted to request the CDC to find an alternative name for the virus.Stumpff 2010 10Radcliffe 2021 376 The name Convict Creek virus was proposed, as the virus was cultured from a mouse captured there, but the CDC rejected this name because USAMRIID, not the CDC, had used the mouse to culture the virus.Harper Meyer 1999 96 Ultimately, the CDC officially named the virus Sin Nombre virus (SNV), Spanish for virus without name.Van Hook 2018 2058Radcliffe 2021 376Johnson 2001 9 The CDC started referring to the disease as hantavirus pulmonary syndrome (HPS) on August 5, 1993,Harper Meyer 1999 94 and made it the official name in October that year.Bales 1994 252note Before hantavirus pulmonary syndrome, the CDC called HPS Navajo flu during their initial response to the outbreak.Burrell 2023 1275 Throughout 1993, the CDC also referred to it variously as hantavirus-associated respiratory disease,CDC MMWR July 30, 1993 570 acute hantavirus-associated respiratory disease,CDC MMWR August 13, 1993 612 hantavirus-associated respiratory illness,CDC MMWR September 17, 1993 707 and acute hantavirus respiratory illness.CDC MMWR October 8, 1993 770 In the press, the disease was also called hantavirus-associated ARDS.Harper Meyer 1999 36 The Hantavirus Study Group, formed to study the clinical course of the disease, published their findings in the April 7, 1994, edition of The New England Journal of Medicine. They reported 18 people who had either serologic or PCR evidence of infection, most of them young adults. Physical examination of these people showed fever, rapid and shallow breathing (tachypnea), an abnormally fast heart rate (tachycardia), and low blood pressure (hypotension). Severe pulmonary edema occurred in nearly all cases. Laboratory findings included hypoxemia, hemoconcentration, higher than normal white blood cell count in the blood(leukocytosis), abnormally low platelet levels in the blood (thrombocytopenia), and increased time needed for the liver to produce prothrombin and for blood to clot.Van Hook 2018 2058 According to the CDC, early signs of illness included fever, muscle pain, headache, variable respiratory symptoms such as coughing, and gastrointestinal symptoms such as abdominal pain, nausea, andvomiting. The early stage of the disease was then followed by sudden respiratory distress. Bilateral pulmonary infiltrates developed within two days of hospitalization, and fever, low oxygen levels (hypoxia), and hypotension were present during hospitalization. People who recovered from HPS during the outbreak did not experience any long-term complications.CDC MMWR October 29, 1993 817 Death was the result of pulmonary edema or heart failure.Harper Meyer 1999 39–40 Government response thumb|alt=A photograph of the building of the Navajo Nation Council Chambers in Window Rock, Arizona|Window Rock, Arizona, where Navajo medicine men met to discuss the outbreak, is the capital of the Navajo Nation. Pictured is the Navajo Nation Council Chamber building in Window Rock. Fifty Navajo medicine men met in Window Rock, Arizona,note Sources differ on when the meeting of 50 Navajo medicine men took place. Stumpff says this meeting occurred "by May,"Stumpff 2010 3 Donovan on May 25, and Sternberg on June 1. to discuss the outbreak and told people to be wary of deer mice and prairie dogs.Stumpff 2010 3 Navajo elders were aware of the danger of mouse feces and urine, so they recommended burning contaminated clothing and keeping food away from mice.Stumpff 2010 3 At the same time, Navajo medicine men performed blessings and purification ceremonies at locations involved in the outbreak, such as places where people fell ill.Bales 1994 258 The Navajo Nation's government responded to the outbreak by declaring a public health emergency and establishing an Incident Management Team and Inter-Agency Working Group. They also implemented rodent control and public health education programs, providing rat traps to residents and informing them about HPS and ways to reduce their risk of exposure to infectedmice.Burrell 2023 1275–1277Harper Meyer 1999 79–81 The government opened a toll-free telephone hotline on June 3 to provide updated information about unexplained respiratory illness and to receive calls about suspected HPS throughout the country.Tappero Khan Pinner Wenger 1996 sec. "Abstract" Public health officials advised people to prevent rodents from entering their homes, avoid leaving out food that could attract them, and trap and dispose of rodents while wearing rubber gloves and surgical masks. To deal with rodent excretions, health officials recommended soaking them in a chlorine bleach solution and then wrapping them in double plastic bags before disposing of them. People were warned to avoid inhaling dust in places infested with mice because the dust could have aerosols that contain thevirus. Health officials did not recommend poisoning mice since they could die somewhere inaccessible and still spread the virus.Bales 1994 257–258Harper Meyer 1999 37 Medical care provided during the outbreak included preventing secondary infections and supporting the body's functions during recovery.Harper Meyer 1999 87 Many of the infected were placed on ventilators, often while sedated.Harper Meyer 1999 88 Most rural physicians attempted to stabilize people suspected to have HPS and transport them to other facilities such as the UNM medical center in Albuquerque.Harper Meyer 1999 87 Large regional hospitals, particularly the one at UNM, had higher survival rates due to easier access to equipment and expertise.Harper Meyer 1999 88 On June 4, the antiviral drug ribavirin was made available for treatment, and intravenous ribavirin stocks were provided to healthcare facilities in the Four Corners region. Intravenous administration of ribavirin had effectively treated severe Hantaan virus infections when provided early during illness, so it was tested experimentally on suspected cases during the outbreak.CDC MMWR June 18, 1993 442–443Harper Meyer 1999 85–86 The CDC considered removing the possibility of infection by trapping and poisoning deer mice, but this was rejected as infeasible given the large geographic area and undesirable since mice are an important part of the ecosystem.Stumpff 2010 7 Social and economic impact During the outbreak, national media were not respectful of the traditional four-day mourning period in Navajo culture.Bales 1994 256 The local community was inundated with media who took pictures of funerals, published the names of the deceased, and attempted to interview families of the deceased. Sometimes, the media incorrectly reported the names of the deceased andcommunities.Bales 1994 257 According to Stumpff, media coverage often caused people to view Navajo culture negatively and associate the disease with the Four Corners,Stumpff 2010 4 and the disease was publicly referred to as various names related to the area, including Navajo Flu, Navajo Illness, and Four Corners Illness.Radcliffe 2021 376 In many instances, residents posted anti-media signs along roads.Pressley SA June 18, 1993 Navajos Protest Response to Mystery Flu Outbreak https://www.washingtonpost.com/archive/politics/1993/06/19/navajos-protest-response-to-mystery-flu-outbreak/0e17c578-26d6-411d-8c97-6382429ec3dd/ The Washington Post https://web.archive.org/web/20210707154910/https://www.washingtonpost.com/archive/politics/1993/06/19/navajos-protest-response-to-mystery-flu-outbreak/0e17c578-26d6-411d-8c97-6382429ec3dd/ July 7, 2021 January 4, 2025 live Some people felt so much resentment that they refused to assist investigators, who also failed to respect mourning practices as they continuously asked for information about recent deaths.Radcliffe 2021 376 Within a month of the outbreak's discovery, it was apparent that HPS was not restricted to the Navajo or the Four Corners region. By that point, however, the Navajo were left to deal with the stigma created by the media, which moved on to other news.note According to Duane Beyal, the executive press officer of the Navajo Nation, local media tended to report on the outbreak better than national outlets. He did, however, praise national media such as Reuters for responding well to criticism.Bales 1994 259 Before the disease's transmission method was confirmed, there was widespread fear that it was contagious. This contributed to discrimination and racism against the Navajo. For example, some restaurants refused to serve Navajo people, while in others staff wore gloves when serving them or threw away their used plates instead of re-using them. People's fears were intensified by the high case fatality rate of HPS even though there was no evidence for transmission between people.Radcliffe 2021 376 Because of these fears, local restaurants saw a significant decline in business, many people stopped going to the movies, and hardly any people attended the annual Gallup Inter-Tribal Indian Ceremonial that was held that year. Some people wore surgical masks when leaving the house. In general, though, people in the area only went outside when necessary. In response to news reports, numerous people canceled vacations to the area, and revenue from tourism declined.Stumpff 2010 4 Peterson Zah, the president of the Navajo Nation, was a vocal critic of the news coverage of the outbreak and the stigmatization of the Navajo. He said: "The story of hantavirus is a perfect example of an intercultural setting and the friction that lies just beneath the surface, and which explodes when unknowing outsiders trample on age-old customs. Deaths and the unknown nature of the illness served only to reinforce stereotypes... [and] the view of Indians as second-class citizens was further supported."Radcliffe 2021 376 During the outbreak, Zah appealed to the media to respect the privacy of people who lost family membersBales 1994 256 and urged tribal members to assist medical investigators.Harper Meyer 1999 43 Before the cause of the outbreak was identified, many Navajo speculated that the disease was brought to the reservation by tourists or that Fort Wingate, located 20 miles (32km) south of the reservation, had stored a biological or chemical weapon that escaped, because the US Army was closing its depot there at the time of the outbreak. Later on, some Navajo expressed skepticism toward the connection to mice. One chapter president instead blamed toxic wastes or radioactivity for causing the outbreak.note In the Navajo Nation, Chapters are the local form of government, and the Chapter President is an elected official.Local Governance Act of 1998 https://www.omb.navajo-nsn.gov/Mandates/Local-Governance-Act Navajo Nation live https://web.archive.org/web/20250224161720/https://www.omb.navajo-nsn.gov/Mandates/Local-Governance-Act February 24, 2025 April 7, 2025 Historical analysis thumb|alt=An image showing El Niño's effects on winter weather in North America|El Niño increases wetness in the southern United States during winter. A group of UNM biologists studying deer mice near the Four Corners region at the timeVan Hook 2018 2058 noticed that their population significantly grew from May 1992 to May 1993.Harper Meyer 1999 64–68 Working with environmental scientists,Van Hook 2018 2059 they demonstrated that the conditions of the 1991–1992 El Niño caused a relatively warm 1992–1993 winter and a rainy 1993 spring in the Four Corners region.Fimrite P September 23, 2012 Hantavirus Outbreak Puzzles Experts https://www.sfgate.com/health/article/hantavirus-outbreak-puzzles-experts-3888327.php SFGate live https://web.archive.org/web/20220707040756/https://www.sfgate.com/health/article/hantavirus-outbreak-puzzles-experts-3888327.php July 7, 2022 January 4, 2025 The area had been experiencing drought for a few years,Borowski S January 13, 2013 The Virus That Rocked the Four Corners Reemerges https://www.aaas.org/taxonomy/term/10/virus-rocked-four-corners-reemerges American Association for the Advancement of Science live https://web.archive.org/web/20250325231039/https://www.aaas.org/taxonomy/term/10/virus-rocked-four-corners-reemerges March 25, 2025 January 4, 2025 but with more snowmelt and rainfall came a relative abundance of springtime vegetation in the region.Van Hook 2018 2059 This provided more shelter and food for local animals, which led to rapid growth of the rodent population and, in turn, increased the number of interactions between humans and rodents.Van Hook 2018 2059Harper Meyer 1999 236Douglas Payne Sabino-Santos Agard 2021 sec. "Introduction" Furthermore, with a higher population density of mice, SNV was able to spread more easily among them.Stumpff 2010 6Harper Meyer 1999 72 According to traditional Navajo beliefs, mice inhabit the nocturnal and outdoor world and humans the daytime and indoor world. The two should not mix or sickness and death may occur. When mice enter a house and find a disorderly environment with food lying about, they become angry at the mess and may strike down a family member, usually someone young and healthy.Stumpff 2010 3 Navajo oral tradition spoke of past outbreaks in 1918, 1933, and 1934, which they attributed to excess caused by disharmony. Every year in which an outbreak occurred had excess rain andsnowfall, which led to increased rodent food supply and consequently greater rodent populations and more human-rodent interactions.MacDonald J March 14, 2018 Solving a Medical Mystery with Oral Traditions https://daily.jstor.org/solving-a-medical-mystery-with-oral-traditions/ JSTOR Daily live https://web.archive.org/web/20240623022222/https://daily.jstor.org/solving-a-medical-mystery-with-oral-traditions/ June 23, 2024 January 4, 2025 Genetic analysis of SNV has indicated that it has existed in its natural reservoir since long before the outbreak.Johnson 2001 9 Biologists believe that people probably died from hantavirus infection before the outbreak but that their cause of death was unknown. Tempest, when recollecting on people he had treated in the years before the outbreak, said: "I will never be able to know for sure but I believe they were also Hantavirus victims." Serum samples collected in 1991 and 1992 as part of the Navajo Health and Nutrition Survey were tested in June 1993 and showed that three people out of 270 had antibodies to hantaviruses, indicative of past infection.CDC MMWR June 18, 1993 441Harper Meyer 1999 204 By examining tissue samples from people who died from unexplained acute respiratory distress syndrome (ARDS), a 38-year-old man who died in Utah in 1959 became the earliest confirmed instance ofHPS. HPS since the outbreak thumb|alt=A photograph of tent cabins in Curry Village in Yosemite National Park, California|Tent cabins in Curry Village in Yosemite National Park, California. A small outbreak of HPS occurred in the park in 2012, mainly at Curry Village, during which ten visitors were infected and three died.November 1, 2012 Outbreak of Hantavirus Infection in Yosemite National Park https://www.cdc.gov/hantavirus/outbreaks/yosemite/index.html Centers for Disease Control and Prevention https://web.archive.org/web/20170128112041/https://www.cdc.gov/hantavirus/outbreaks/yosemite/index.html January 28, 2017 March 25, 2025CDC MMWR November 23, 2012 952 Following the outbreak, the medical community in the US was asked to report HPS-like illnesses with unexplained causes. Other hantaviruses responsible for HPS were subsequently found, including Bayou virus, Black Creek Canal virus, and New York virus. The disease has since been found to also occur in Canada, Panama, and most of South America.Vial Ferrés Vial Klingström 2023 e373 In the Navajo Nation, the government has implemented long-term prevention and control strategies to address HPS, including rodent control and surveillance programs and public health education,Burrell 2023 1277 andtheCDC Foundation has worked with the Navajo community to implement rodent control measures and educate people about HPS.June 3, 2020 A Unique Partnership Tackles Hantavirus in the Navajo Nation https://www.cdcfoundation.org/stories/unique-partnership-tackles-hantavirus-navajo-nation CDC Foundation live https://web.archive.org/web/20241207105241/https://www.cdcfoundation.org/stories/unique-partnership-tackles-hantavirus-navajo-nation December 7, 2024 April 18, 2025 SNV is the most common cause of HPS in North America.Chen Gong Wang Sun 2023 sec. "Diseases Caused by Hantaviruses" It is primarily associated with one rodent species, and other hantaviruses discovered in North America follow the same pattern.Chen Gong Wang Sun 2023 sec. "Taxonomy and Distribution of Hantaviruses"Van Hook 2018 2059 Infections are usually contracted by inhaling aerosols of rodent feces, urine, or saliva.Chen Gong Wang Sun 2023 sec. "Transmission of Hantaviruses"Vial Ferrés Vial Klingström 2023 e371 A few dozen cases occur each year,Chen Gong Wang Sun 2023 sec. "Diseases Caused by Hantaviruses" most from April to August in rural areas in western states and provinces.Warner Dowhanik Audet Grolla 2020 3021–3022 In South America, Andes virus is the most common cause of HPS and is transmitted primarily by the long-tailed pygmy rice rat.Chen Gong Wang Sun 2023 sec. "Diseases Caused by Hantaviruses"Medina Torres-Perez Galeno Navarrete 2009 sec. "Abstract" More than 200 cases occur every year, mostly in Argentina, Brazil, and Chile.Vial Ferrés Vial Klingström 2023 e373 Although HPS was feared by many to be contagious during the 1993 outbreak, transmission of SNV between people has never been confirmed,Krüger Schönrich Klempa 2011 687 and there is little evidence of human-to-human transmission of hantaviruses in general.Toledo Haby Reveiz Sosa Leon 2022 1367Tortosa Perre Tognetti Lossetti 2024 sec. "Introduction" Because of the health risks imposed by hantaviruses, however, rodents and other small mammals are routinely surveilled to monitor hantavirus circulation.Pottinger 2005 49Castel Filippone Tatard Vigan 2023 20–21 Environmental factors influence the rodent population, which can make HPS more or less frequent. For example, harsher wet winters are associated with a smaller deer mouse population,Deer Mouse Monitoring https://www.nps.gov/im/medn/deer-mouse.htm National Park Service live https://web.archive.org/web/20250909235547/https://www.nps.gov/im/medn/deer-mouse.htm September 9, 2025 November 3, 2025 while rainfall is beneficial to their population by increasing food availability.Douglas Payne Sabino-Santos Agard 2021 sec. "Rainfall or Precipitation Factor" Consequently, lower winter temperatures are associated with lower HPS incidence, and greater rainfall is associated with higher HPS incidence.Tian Stenseth 2021 sec. "Environmental factors that trigger hantavirus disease outbreaks" Treatment of HPS is supportive and includes cardiac monitoring, mechanical ventilation, and extracorporeal membrane oxygenation.May 23, 2024 Clinician Brief: Hantavirus Pulmonary Syndrome (HPS) https://www.cdc.gov/hantavirus/hcp/clinical-overview/hps.html Centers for Disease Control and Prevention live https://web.archive.org/web/20251012054047/https://www.cdc.gov/hantavirus/hcp/clinical-overview/hps.html October 12, 2025 November 3, 2025 Despite these measures, the disease still has a high case fatality rate, ranging from about 12% to 45%, varying by virus.Vial Ferrés Vial Klingström 2023 e373 Experimental testing of ribavirin during the outbreak did not show a significant benefit to its use,Harper Meyer 1999 86 and research has since shown that it is ineffective if administered after the early stage of HPS.Vial Ferrés Vial Klingström 2023 e377Dheerasekara Sumathipala Muthugala 2020 412 As a result, the CDC does not recommend ribavirin as a treatment for the disease. Additionally, there are no approved vaccines to protect against New World hantavirus infections.Vial Ferrés Vial Klingström 2023 e379Chai Wang Du Jiang 2025 sec. "Introduction" To prevent infection, the CDC advises people to avoid contact with rodents, prevent them from entering one's home, keep one's home clear of food that may attract them, and safely clean up after them.May 13, 2024 Hantavirus Prevention https://www.cdc.gov/hantavirus/prevention/index.html Centers for Disease Control and Prevention live https://web.archive.org/web/20250301234907/https://www.cdc.gov/hantavirus/prevention/index.html March 1, 2025 March 16, 2025April 8, 2024 Controlling Wild Rodent Infestations https://www.cdc.gov/healthy-pets/rodent-control/index.html Centers for Disease Control and Prevention live https://web.archive.org/web/20251012054020/https://www.cdc.gov/healthy-pets/rodent-control/index.html October 12, 2025 November 3, 2025 See also Viruses MV Hondius hantavirus outbreak Notes note References 30em Books Harper DR, Meyer AS 1999 Of Mice, Men, and Microbes: Hantavirus https://books.google.com/books?id=zqCxSxXh5aQC&pg=PA1 Academic Press 978-0-08-049198-1 Johnson KM 2001 Hantaviruses: History and Overview Schmaljohn C Nichol ST Hantaviruses https://books.google.com/books?id=r16PteBa_2kC&pg=PA9 Springer Berlin Heidelberg 9–10 978-3-540-41045-4 Journal articles Avšič-Županc T, Saksida A, Korva M April 2019 Hantavirus Infections Clin Microbiol Infect 21S e6–e16 10.1111/1469-0691.12291 free 24750436 Bales F June 1, 1994 Hantavirus and the Media: Double Jeopardy for Native Americans https://escholarship.org/uc/item/36c7c36t Am Indian Cult Res J 18 3 251–263 0161-6463 Brathwaite Dick O, San Martín JL, Montoya RH, del Diego J, Zambrano B, Dayan GH October 2012 The History of Dengue Outbreaks in the Americas Am J Trop Med Hyg 87 4 584–593 10.4269/ajtmh.2012.11-0770 3516305 23042846 Bui-Mansfield LT, Cressler DK November 2011 Imaging of Hemorrhagic Fever With Renal Syndrome: A Potential Bioterrorism Agent of Military Significance Mil Med 176 11 1327–1334 10.7205/milmed-d-11-00048 22165665 Burrell D November 7, 2023 Hantavirus Pulmonary Syndrome (HPS), Native Communities and Public Health Epidemic Surveillance in the United States Arab Gulf J Sci Res 42 4 1271–1286 10.1108/agjsr-04-2023-0165 free Castel G, Filippone C, Tatard C, Vigan J, Dobigny G January 2023 Role of Seaports and Imported Rats in Seoul Hantavirus Circulation, Africa Emerg Infect Dis 29 1 20–25 10.3201/eid2901.221092 9796207 36573519 Centers for Disease Control and Prevention June 18, 1993 Update: Outbreak of Hantavirus Infection—Southwestern United States, 1993 https://www.cdc.gov/Mmwr/preview/mmwrhtml/00020807.htm MMWR Morb Mortal Wkly Rep 42 23 441–443 8502218 CDC MMWR June 18, 1993 Centers for Disease Control and Prevention June 25, 1993 Update: Outbreak of Hantavirus Infection—Southwestern United States, 1993 https://www.cdc.gov/mmwr/preview/mmwrhtml/00021008.htm MMWR Morb Mortal Wkly Rep 42 24 477–479 8510634 CDC MMWR June 25, 1993 Centers for Disease Control and Prevention July 9, 1993 Update: Hantavirus Infection–United States, 1993 https://www.cdc.gov/mmwr/preview/mmwrhtml/00021088.htm MMWR Morb Mortal Wkly Rep 42 26 517–519 8515743 CDC MMWR July 9, 1993 Centers for Disease Control and Prevention July 30, 1993 Hantavirus Disease — Southwestern United States, 1993 https://www.cdc.gov/mmwr/preview/mmwrhtml/00021294.htm MMWR Morb Mortal Wkly Rep 42 29 570–572 8332114 CDC MMWR July 30, 1993 Centers for Disease Control and Prevention August 13, 1993 Update: Hantavirus Disease—United States, 1993 https://www.cdc.gov/mmwr/preview/mmwrhtml/00021360.htm MMWR Morb Mortal Wkly Rep 42 31 612–614 8336693 CDC MMWR August 13, 1993 Centers for Disease Control and Prevention September 17, 1993 Update: Hantavirus-Associated Illness — North Dakota, 1993 https://www.cdc.gov/mmwr/preview/mmwrhtml/00021830.htm MMWR Morb Mortal Wkly Rep 42 36 707 8361465 CDC MMWR September 17, 1993 Centers for Disease Control and Prevention October 8, 1993 Progress in the Development of Hantavirus Diagnostic Assays — United States https://www.cdc.gov/mmwr/preview/mmwrhtml/00022006.htm MMWR Morb Mortal Wkly Rep 32 39 770–771 8413161 CDC MMWR October 8, 1993 Centers for Disease Control and Prevention October 29, 1993 Update: Hantavirus Pulmonary Syndrome—United States, 1993 https://www.cdc.gov/Mmwr/preview/mmwrhtml/00030705.htm MMWR Morb Mortal Wkly Rep 42 42 816–820 8413161 CDC MMWR October 29, 1993 Centers for Disease Control and Prevention January 28, 1994 Update: Hantavirus Pulmonary Syndrome—United States, 1993 https://www.cdc.gov/mmwr/preview/mmwrhtml/00025007.htm MMWR Morb Mortal Wkly Rep 43 3 45–48 8283965 CDC MMWR January 28, 1994 Centers for Disease Control and Prevention August 11, 2000 Fatal Illnesses Associated With a New World Arenavirus–California, 1999–2000 https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4931a1.htm MMWR Morb Mortal Wkly Rep 49 31 709–711 10958585 CDC MMWR August 11, 2000 Centers for Disease Control and Prevention November 23, 2012 Hantavirus Pulmonary Syndrome in Visitors to a National Park—Yosemite Valley, California, 2012 https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6146a5.htm MMWR Morb Mortal Wkly Rep 61 46 952 23169317 CDC MMWR November 23, 2012 Chai S, Wang L, Du H, Jiang H February 17, 2025 Achievement and Challenges in Orthohantavirus Vaccines Vaccines 13 2 198 10.3390/vaccines13020198 free 11861054 40006744 Chen R, Gong H, Wang X, Sun M, Ji Y, Tan S, Chen J, Shao J, Liao M August 8, 2023 Zoonotic Hantaviridae with Global Public Health Significance Viruses 15 8 1705 10.3390/v15081705 free 10459939 37632047 Clement J, LeDuc JW, Lloyd G, Reynes JM, McElhinney L, Van Ranst M, Lee HW July 17, 2019 Wild Rats, Laboratory Rats, Pet Rats: Global Seoul Hantavirus Disease Revisited Viruses 11 7 652 10.3390/v11070652 free 6669632 31319534 Dheerasekara K, Sumathipala S, Muthugala R 2020 Hantavirus Infections-Treatment and Prevention Curr Treat Options Infect Dis 12 4 410–421 10.1007/s40506-020-00236-3 7594967 33144850 Douglas KO, Payne K, Sabino-Santos G, Agard J December 23, 2021 Influence of Climatic Factors on Human Hantavirus Infections in Latin America and the Caribbean: A Systematic Review Pathogens 11 1 15 10.3390/pathogens11010015 free 8778283 35055965 Finkbeiner A, Khatib A, Upham N, Sterner B June 10, 2025 A Systematic Review of the Distribution and Prevalence of Viruses Detected in the Peromyscus maniculatus Species Complex (Rodentia: Cricetidae) PLoS Pathog 21 6 e1013125 10.1371/journal.ppat.1013125 free 12201646 40493689 Fulhorst CF, Bowen MD, Ksiazek TG, Rollin PE, Nichol ST, Kosoy MY, Peters CJ October 1, 1996 Isolation and Characterization of Whitewater Arroyo Virus, a Novel North American Arenavirus Virology 224 1 114–120 10.1006/viro.1996.0512 8862405 Gonzalez JP, Souris M, Valdivia-Granda W 2018 Global Spread of Hemorrhagic Fever Viruses: Predicting Pandemics Methods Mol Biol 1604 3–31 10.1007/978-1-4939-6981-4_1 7120037 28986822 Greenbaum IF, Honeycutt RL, Chirhart SE October 11, 2019 Taxonomy and Phylogenetics of the Peromyscus maniculatus Species Group Special Publications of the Museum of Texas Tech University 71 559–575 10.5281/zenodo.7221125 Koehler FC, Di Cristanziano V, Späth MR, Hoyer-Allo KJ, Wanken M, Müller RU, Burst V January 29, 2022 The Kidney in Hantavirus Infection—Epidemiology, Virology, Pathophysiology, Clinical Presentation, Diagnosis and Management Clin Kidney J 15 7 1231–1252 10.1093/ckj/sfac008 9217627 35756741 Krüger DH, Schönrich G, Klempa B June 2011 Human Pathogenic Hantaviruses and Prevention of Infection Hum Vaccin 7 6 685–693 10.4161/hv.7.6.15197 3219076 21508676 Kuhn JH, Schmaljohn CS February 28, 2023 A Brief History of Bunyaviral Family Hantaviridae Diseases 11 1 38 10.3390/diseases11010038 free 10047430 36975587 Mariappan V, Pratheesh P, Shanmugam L, Rao SR, Pillai AB July 16, 2021 Viral Hemorrhagic Fever: Molecular Pathogenesis and Current Trends of Disease Management-An Update Curr Res Virol Sci 2 100009 10.1016/j.crviro.2021.100009 free Medina RA, Torres-Perez F, Galeno H, Navarrete M, Vial PA, Palma RE, Ferres M, Cook JA, Hjelle B March 2009 Ecology, Genetic Diversity, and Phylogeographic Structure of Andes Virus in Humans and Rodents in Chile J Virol 83 6 2446–2459 10.1128/JVI.01057-08 2648280 19116256 Pottinger R Spring 2005 Hantavirus in Indian Country: The First Decade in Review https://escholarship.org/content/qt5nb7375m/qt5nb7375m_noSplash_3a9e7bb49aedc610ae4ddb1f75d2c849.pdf Am Indian Cult Res J 29 2 35–56 Price HL, Clancy NP, Graham TE, Kersten SM, Lavengood KD, Paddock SA, Shoemaker CC, Yeager C, Lehmer EM March 1, 2014 Why Is the Four Corners a Hotspot for Hantavirus? BIOS 85 1 38–47 10.1893/0005-3155-85.1.38 Radcliffe C June 30, 2021 The Tragedy of Names Yale J Biol Med 94 2 375–378 8223546 34211356 Salles TS, da Encarnação Sá-Guimarães T, de Alvarenga ES, Guimarães-Ribeiro V, de Meneses MD, de Castro-Salles PF, Dos Santos CR, do Amaral Melo AC, Soares MR, Ferreira DF, Moreira MF April 24, 2018 History, Epidemiology and Diagnostics of Dengue in the American and Brazilian Contexts: A Review Parasit Vectors 11 1 264 10.1186/s13071-018-2830-8 free 5937836 29690895 Tappero JW, Khan AS, Pinner RW, Wenger JD, Graber JM, Armstrong LR, Holman RC, Ksiazek TG, Khabbaz RF February 7, 1996 Utility of Emergency, Telephone-Based National Surveillance for Hantavirus Pulmonary Syndrome. Hantavirus Task Force JAMA 275 5 398–400 8569020 Tian H, Stenseth NC February 21, 2021 The Ecological Dynamics of Hantavirus Diseases: From Environmental Variability to Disease Prevention Largely Based on Data From China PLOS Negl Trop Dis 13 2 e0006901 10.1371/journal.pntd.0006901 free 6383869 30789905 Toledo J, Haby MM, Reveiz L, Sosa Leon L, Angerami R, Aldighieri S October 17, 2022 Evidence for Human-to-Human Transmission of Hantavirus: A Systematic Review J Infect Dis 226 8 1362–1371 10.1093/infdis/jiab461 9574657 34515290 Tortosa F, Perre F, Tognetti C, Lossetti L, Carrasco G, Guaresti G, Iglesias A, Espasandin Y, Izcovich A 19 September 2024 Seroprevalence of Hantavirus Infection in Non-Epidemic Settings Over Four Decades: A Systematic Review and Meta-Analysis BMC Public Health 24 1 2553 10.1186/s12889-024-20014-w free 11414058 39300359 Van Hook CJ November 2018 Hantavirus Pulmonary Syndrome—The 25th Anniversary of the Four Corners Outbreak Emerg Infect Dis 24 11 2056–2060 10.3201/eid2411.180381 6199996 Vial PA, Ferrés M, Vial C, Klingström J, Ahlm C, López R, Le Corre N, Mertz GJ September 2023 Hantavirus in Humans: A Review of Clinical Aspects and Management Lancet Infect Dis 23 9 e371–e382 10.1016/S1473-3099(23)00128-7 37105214 Warner BM, Dowhanik S, Audet J, Grolla A, Dick D, Strong JE, Kobasa D, Lindsay LR, Kobinger G, Feldmann H, Artsob H, Drebot MA, Safronetz D December 2020 Hantavirus Cardiopulmonary Syndrome in Canada Emerg Infect Dis 26 12 3020–3024 10.3201/eid2612.202808 7706972 33219792 Whitmer SL, Whitesell A, Mobley M, Talundzic E, Shedroff E, Cossaboom CM, Messenger S, Deldari M, Bhatnagar J, Estetter L, Zufan S, Cannon D, Chiang CF, Gibbons A, Krapiunaya I, Morales-Betoulle M, Choi M, Knust B, Amman B, Montgomery JM, Shoemaker T, Klena JD July 11, 2024 Human Orthohantavirus Disease Prevalence and Genotype Distribution in the U.S., 2008–2020: A Retrospective Observational Study Lancet Reg Health Am 37 100836 10.1016/j.lana.2024.100836 11296052 39100240 Other Stumpff LM 2010 Hantavirus and the Navajo Nation: A Double Jeopardy Disease https://www4.evergreen.edu/sites/default/files/Stumpff%2520hantavirus.pdf The Evergreen State College live https://web.archive.org/web/20250325231545/https://www4.evergreen.edu/sites/default/files/Stumpff%2520hantavirus.pdf March 25, 2025 March 7, 2025 Further reading Duchin JS, Koster FT, Peters CJ, Simpson GL, Tempest B, Zaki SR, Ksiazek TG, Rollin PE, Nichol S, Umland ET, et al. April 7, 1994 Hantavirus Pulmonary Syndrome: A Clinical Description of 17 Patients with a Newly Recognized Disease. The Hantavirus Study Group N Engl J Med 330 14 949–955 10.1056/NEJM199404073301401 8121458 — the Hantavirus Study Group's publication about HPS Peters CJ, Olshaker M April 13, 1998 Virus Hunter: Thirty Years of Battling Hot Viruses Around the World Anchor Books 978-0-385-48558-6 — contains a firsthand account of the outbreak from the perspective of C. J. Peters, the head of the CDC's Special Pathogens Branch External links The CDC's index page for information about hantaviruses and hantaviral disease ViralZone's article about the molecular biology of orthohantaviruses The Bacterial and Viral Bioinformatics Resource Center's overview page for bioinformatic information about hantaviruses collapsed Category:1993 disease outbreaks Category:1993 disasters in the United States Category:Rodent-carried diseases Category:Hantavirus outbreaks Category:Disease outbreaks in the United States Category:History of the Southwestern United States Category:Navajo history