Civilian Outbreak of Adenovirus Acute Respiratory Disease -- South Dakota, 1997

Adenoviruses are human pathogens that commonly infect the respiratory and gastrointestinal tracts (1). Adenovirus infections are endemic, particularly among children, but also may cause epidemics of pharyngoconjunctival fever, keratoconjunctivitis, gastroenteritis, and acute respiratory disease (ARD) among military trainees. Outbreaks of ARD among adults in the civilian sector are rare (2). In March 1997, an outbreak of acute respiratory disease (ARD) caused by adenovirus serotype 11 occurred among students at a job training facility in South Dakota. This report summarizes the epidemiologic and clinical features of this outbreak and discusses the change in availability of adenovirus vaccines for military use.

The facility provides high school education and vocational training for 240 persons aged 16-21 years. New students matriculate year-round at 2-week intervals and remain for approximately 1-2 years. All students live on campus in one of four barracks-style dormitories (three for males and one for females). Sixty students are housed in each dormitory, with six to 10 persons per room sleeping in bunk beds. Students share a common dining hall. Routine medical care is provided by an infirmary nurse, who refers more severe illnesses to visiting physicians or local hospitals. Hospitalization discharge summaries are forwarded to the infirmary nurse.

Following the outbreak, a chart review was conducted at the facility's infirmary by the infirmary nurse. A case of lower respiratory tract infection (LRTI) was defined as physician-diagnosed pneumonia, an abnormal chest radiograph, or rales or wheezing on pulmonary auscultation in any student. A case of upper respiratory tract infection (URTI) was defined as coryza and sore throat without LRTI in any student. A case of ARD was defined as either URTI or LRTI in any student.

During March 8-28, a total of 146 (61%) students were diagnosed with ARD (Figure_1); 103 (71%) had URTI and 43 (29%) had LRTI. The ARD attack rate was higher among males than females (69% versus 37%, respectively, p less than 0.01). Although students with URTI and LRTI were similar in age and sex, frequencies of associated signs and symptoms differed between the two groups (Table_1). Students with URTI were more likely than students with LRTI to have headache. Students with LRTI were more likely to have fever greater than or equal to 101 F (greater than or equal to 38.3 C), pleuritic chest pain, shortness of breath, lymphadenopathy, vomiting, conjunctivitis, and dysuria (all p-values less than 0.05). Students with LRTI had higher fevers than students with URTI (median maximum temperatures: 103 F {39.4 C} versus 102 F {38.9 C}, p less than 0.001). Five (12%) of 43 students with LRTI were hospitalized for 3 to 7 days each. One ill student with a poorly controlled seizure disorder suffered a respiratory arrest and required intensive care. Staff members at this facility also reported ARD symptoms during this time period.

Throat swab specimens were collected from seven ill students and inoculated into RMK and A549 cells. Six specimens yielded adenovirus, identified as subgenus B by the polymerase chain reaction assay, and as adenovirus 11 by microneutralization assays (2-4). The sequences of a one kilobase region of the fiber gene were identical for all isolates, suggesting a single outbreak strain.

Reported by: O Four Bear, Box Elder Job Corps, Nemo; LM Schaefer, LM Kellen-Anderson, SL Parker, DVM, State Epidemiologist, South Dakota Dept of Health. DP Schnurr, PhD, Viral and Rickettsial Diseases Laboratory, California Dept of Health Svcs. JC Gaydos, MD, Div of Preventive Medicine, Walter Reed Army Institute of Research, Washington, DC. Respiratory and Enteric Viruses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Although adenovirus-associated ARD outbreaks among military training populations are well-described, they have not been recognized among college students or other young adults in the civilian sector. However, the setting of this outbreak of adenovirus ARD is similar to settings of previous military ARD outbreaks. In both settings, young adults live in crowded conditions, and new groups of potentially susceptible persons are introduced regularly. This outbreak differed from military outbreaks because most adenovirus-associated ARD outbreaks among U.S. military trainees are associated with adenoviruses 4 and 7. Adenovirus 11 is most commonly recognized as a cause of hemorrhagic cystitis, acute hemorrhagic conjunctivitis, and illnesses among immunocompromised persons (1,5) and has rarely been associated with ARD in military trainees or in any other immunocompetent adult population (6).

Outbreaks of adenovirus-associated ARD were common among U.S. military trainees before the 1970s, when routine vaccination of this group with oral vaccines against adenovirus serotypes 4 and 7 was instituted (7,8). Although these vaccines were highly effective, their manufacture has been discontinued (9). Residual supplies of the vaccines will probably be exhausted in 1999, at which time large ARD outbreaks in military settings are expected, primarily in winter months (9). This outbreak underscores that adenoviruses can cause outbreaks of ARD among young adults, persons living in crowded conditions, and military recruits.

References

1. Foy HM. Adenoviruses. In: Evans AS, Kaslow RS, eds. Viral infections of humans. 4th ed. New York, New York: Plenum Medical Book Co., 1997:119-38.

2. S¤nchez MP, Erdman DD, T½r½k TJ, Freeman CJ, M¤ty¤s BT. Outbreak of adenovirus 35 pneumonia among adult residents and staff of a chronic care psychiatric facility. J Infect Dis 1997;176:760-3.

3. McDonough M, Kew O, Hierholzer J. PCR detection of human adenoviruses. In: Persing DH, Smith TF, Tenover FC, White TJ, eds. Diagnostic molecular microbiology: principles and applications. Washington, DC: American Society for Microbiology, 1993:389-93.

4. Hierholzer JC. Adenoviruses. In: Lennette EH, Lennette DA, Lennette ET, eds. Diagnostic procedures for viral rickettsial, and chlamydial infections. 7th ed. Washington, DC: American Public Health Association, 1995:169-88.

5. Hierholzer JC. Adenoviruses in the immunocompromised host. Clin Micro Rev 1992;5:262-74.

6. Hierholzer JC, Pumarola A, Rodriguez-Torres A, Beltran M. Occurrence of respiratory illness due to an atypical strain of adenovirus 11 during a large outbreak in Spanish military recruits. Am J Epidemiol 1974;99:434-42.

7. Rubin BA, Rorke LB. Adenovirus vaccines. In: Plotkin SA, Mortimer EA, eds. Vaccines. 2nd ed. Philadelphia, Pennsylvania: WB Saunders Co., 1994:475-502.

8. Gaydos CA, Gaydos JC. Adenovirus vaccines in the US military. Mil Med 1995;6:300-4.

9. Howell MR, Nang RN, Gaydos CA, Gaydos JC. Prevention of adenoviral acute respiratory disease in army recruits: cost-effectiveness of a military vaccination policy. Am J Prev Med 1998;14:168-75.

TABLE 1. Clinical features of students with acute respiratory disease (ARD), upper
respiratory tract infection (URTI), and lower respiratory tract infection (LRTI)* -- South
Dakota, 1997
==============================================================================================
                                     ARD              URTI              LRTI
                                   (n=146)           (n=103)           (n=43)
                                 -----------       ------------      -----------
Clinical features                No.    (%)        No.     (%)       No.    (%)
--------------------------------------------------------------------------------
Coryza                           140    (96)       103    (100)       37    (86)
Sore throat                      139    (95)       103    (100)       36    (84)
Headache                         138    (95)       102    ( 99)       36    (84)
Fever >=101 F (>=38.3 C)          76    (52)        36    ( 35)       40    (93)
Lympadenopathy                    34    (23)        12    ( 12)       22    (51)
Shortness of breath               34    (23)         0       --       34    (79)
Wheezing                          34    (23)         0       --       34    (79)
Conjunctivitis                    30    (21)        13    ( 13)       17    (40)
Pleuritic chest pain              26    (18)         0       --       26    (61)
Vomiting                          22    (15)         4    (  4)       18    (42)
Rales                             22    (15)         0       --       22    (51)
Dysuria or hematuria               3    ( 2)         0       --        3    ( 7)
Abnormal chest radiograph         28    (19)         0       --       28    (65)
--------------------------------------------------------------------------------
* A case of LRTI was defined as physician-diagnosed pneumonia, an abnormal chest radiograph,
  or rales or wheezing on pulmonary auscultation in any student. A case of URTI was defined
  as coryza and sore throat without LRTI in any student. A case of ARD was defined as either
  URTI or LRTI in any student.
==============================================================================================

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