Pathogen Safety Data Sheets: Infectious Substances – Parvovirus B19
PATHOGEN SAFETY DATA SHEET - INFECTIOUS SUBSTANCES
SECTION I - INFECTIOUS AGENT
SYNONYM OR CROSS REFERENCE: Erythrovirus B19, B19V, fifth disease, human parvovirus (HPV), human serum parvovirus-like virus, erythaema infectiosum, slapped-cheek disease, hydrops foetalis, "gloves and socks" syndrome, and "Nakatani virus" in JapanFootnote 1-Footnote 7.
CHARACTERISTICS: Parvovirus 19 is a member of the family Parvoviridae, sub-family Parvovirinae, and genus ErythrovirusFootnote 4. It is classified into three genotypes: genotype 1 (classical B19 strains), genotype 2 (prototype K71- and A6-like strains), and genotype 3 (prototype V9 virus)Footnote 5Footnote 8. Parvovirus B19 is an icosahedral (20 to 25 nm diameter), non- enveloped, single-stranded DNA virusFootnote 2Footnote 5Footnote 9. The virus targets rapidly growing erythroid progenitor cells, which are found in human bone marrow, foetal liver, human umbilical cord, and peripheral bloodFootnote 6. The virus is also found in platelets, and tissues from the heart, liver, lung, kidney, endothelium, and synoviumFootnote 10.
SECTION II - HAZARD IDENTIFICATION
PATHOGENICITY/TOXICITY: Many persons with parvovirus B19 infection are asymptomatic (about 25% of adults and children during outbreak), or exhibit mild, non-specific, cold-like symptoms that are never linked to the virusFootnote 1-Footnote 4Footnote 6. The clinical conditions associated with the infection include erythema infectiosum (Fifth Disease), arthropathy, transient aplastic crisis, chronic red cell aplasia, hydrops foetalis, and papular, purpuric eruptions on the hands and feet (
"gloves and socks" syndrome). Complications t hought to be associated with parvovirus B19 infection include encephalopathy, epilepsy, meningitis, myocarditis, dilated cardiomyopathy, and autoimmune hepatitisFootnote 1Footnote 6.
Erythema infectiosum (Fifth Disease) is the most recognizable presentation of parvovirus B19 infection. It consists of a rash that generally affects children between 4 and 10 years of age, although a less-pronounced rash can occur in adults. Prodromal symptoms are mild, and include fever, coryza, headache, and nausea. The first stage of the rash presents as erythaema of the cheeks (
"slapped-cheek" rash). After 1 to 4 days, t he second stage appears as a maculopapular rash of the extremities and trunk. Central clearance of the rash is possible, giving it a lacy, reticular pattern. The second-stage rash usually lasts 1 to 6 weeks. The third stage may continue for the following 1 to 3 weeks and resolves spontaneously with no permanent sequelaeFootnote 6.
Arthropathy may be a complication of erythaema infectiosum or a primary presentation of infection. Approximately 8% of children infected with the virus have arthralgia; however, it is more common in adolescents and adults, affecting up to 60% of those infected. The pattern of arthropathy differs between adults and children. In children, the pattern can be symmetric or asymmetric and usually involves the knees (82% of patients) and ankles. In adults, the pattern is 2 symmetric and polyarticular and usually involves the proximal interphalangeal and metacarpophalangeal joints. Arthropathy generally resolves within three weeks but can last from months to years, especially in women(Footnote 6).
Transient aplastic crisis as a result of parvovirus B19 infection may occur in persons with decreased erythrocytes, for example due to iron deficiency anaemia, sickle cell disease, HIV, spherocytosis, or thalassaemia. Chronic red cell aplasia may occur in immunocompromised persons infected with parvovirus B19 in the absence of rashes and arthropathyFootnote 6.
In young adults, infection can be associated with papular, purpuric, "gloves and socks" syndrome, which presents as symmetric, painful erythaema and oedema of the feet and hands. A hallmark of the syndrome is a sharp demarcation of the rash at the wrists and ankles, although other areas (e.g., cheeks, elbows, knees, inner thighs, glans of the penis, buttocks, or vulva) may also be involved. Patients may experience fever, arthralgia, or both. Symptoms usually resolve within 1 to 3 weeks without scarringFootnote 6.
A major concern with foetal infection is the development of foetal anaemia. Thrombocytopenia may be present in addition to anaemia. Infection in the first trimester may result in foetal loss or miscarriage. Infection in the second and third trimester may result in foetal anaemia, myocarditis, high output cardiac failure, hydrops foetalis, and stillbirth. Foetal death may occur in up to 10% of infected foetusesFootnote 11.
EPIDEMIOLOGY: Persons with blood group P antigen (the receptor for B19 erythroid cells) are universally susceptible to Parvovirus B19Footnote 2. Virus strains are found in Western Europe, United States, and Brazil, with a lower prevalence of genotype 1 strain compared to the other strains. Genotype 3 is endemic in Ghana, West AfricaFootnote 5. Infection can occur in sporadic or epidemic forms, and can occur in any month of the year, and. In temperate climates, epidemic manifestations are more common in late winter, spring, and early summer, with epidemic peaks every 3 to 7 years in a given community. Over a 2 to 6 months observed outbreak period, the susceptibility rates are 50% in household contacts, and 10% to 60% in the day care or school settings. In the United States, 50 to 60% of adults have serological evidence of past infection, depending on age and locationFootnote 2Footnote 4. Arthropathy appears to affect women twice as often as menFootnote 6. The prevalence of IgG antibodies directed against B19 ranges from 2 to 15% in children 1 to 5 years old, 15 to 60% in children 6 to 19 years old, 30 to 60% in adults, and more than 85% in the geriatric populationFootnote 1. The infectiousness of the virus has also been observed in the occupational setting among hospital staff and research laboratoriesFootnote 2Footnote 3Footnote 12Footnote 13.
INFECTIOUS DOSE: Unknown. In a study of B19 seronegative plasma pool-recipients, it was shown that only those recipients who received plasma containing greater than 10Footnote 7 genome copies/ml became infected or seroconverted(Footnote 14,Footnote 15); however, it has also been proposed that products with much lower virus DNA concentrations (e.g., 10Footnote 1 geq/ml or even lower) would transmit the virus(Footnote 16)
MODE OF TRANSMISSION: Transmission occurs most commonly by personal contact, via aerosols, respiratory secretions, or saliva droplets. It can also be transmitted vertically from mother to foetus or via transfusion of blood and contaminated blood products (especially pooled factor VIII and factor IX concentrates), and organ transplantation (iatrogenic nosocomial infections)Footnote 2-Footnote 5Footnote 10Footnote 17. The risk of vertical transmission to the foetus is approximately 33%Footnote 11.
INCUBATION PERIOD: Four to 14 days, but can last as long as 21 daysFootnote 2.
COMMUNICABILITY: Illness is most communicable before the onset of rash in people with rash illness alone, and probably not communicable thereafter because viraemia has been cleared by this pointFootnote 6. Patients are highly contagious during aplastic crisis and should be isolated to prevent transmission of the virusFootnote 6. Individuals with aplastic crisis are communicable up to 1 week after onset of symptoms. Immunosuppressed people with chronic infection and severe anaemia may be infectious for months to yearsFootnote 2.
SECTION IV - STABILITY AND VIABILITY
DRUG SUSCEPTIBILITY: None currently availableFootnote 18.
SUSCEPTIBILITY TO DISINFECTANTS: Treatment with formaldehyde or β-propiolactone destroys the antigenicity of the virusFootnote 12. Parvovirus B19 may be sensitive to a 5 minute contact at room temperature with sodium hypochlorite (3,000 to 5,000 ppm free chlorine), and accelerated hydrogen peroxide (5,000 ppm)Footnote 19-Footnote 21.
SURVIVAL OUTSIDE HOST: It is difficult to cultivate in vitro. Serum samples containing the virus can be stored for short periods at 4°C and for longer periods at -70°C for virus detectionFootnote 4.
SECTION V - FIRST AID / MEDICAL
SURVEILLANCE: If erythaema infectiosum is present, a clinical diagnosis can be made without laboratory testingFootnote 6. Serum IgM testing is recommended to diagnose acute viral infection in immunocompetent patients. Elevated IgM antibodies will remain detectable for 2 to 3 months after acute infection. IgG testing is less useful because it only indicates previous infection and immunity. Viral DNA testing is crucial for the diagnosis of infection in patients in transient aplastic crisis or in immunocompromised patients with chronic infectionFootnote 6Footnote 22. PCR assays are preferred over less sensitive nucleic acid hybridization assaysFootnote 6. ELISA- and haemagglutination-based assays have been developed to detect viral antigen during blood screeningFootnote 14. Other methods such as detection of B19 protein production by immunofluorescence staining and quantitative PCR methods have been developed for laboratory diagnosisFootnote 23.
Note: All diagnostic methods are not necessarily available in all countries.
FIRST AID/TREATMENT: Erythaema infectiosum is usually self-limited and does not require treatmentFootnote 6. Generally, no specific therapy is required for parvovirus B19 infection in immunocompetent individualsFootnote 10. Treatment of symptoms such as fever, pain, or itching may be required. Adults with joint pain and swelling may require rest and anti-inflammatory drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs), to relieve symptomsFootnote 1. Pure red-cell aplasia and the underlying persistent infection may be terminated by discontinuing immunosuppressive therapy, or by instituting antiretroviral drug therapy in patients with AIDSFootnote 3. Patients in transient aplastic crisis may require erythrocyte transfusions. Chronic red cell aplasia, if severe, may require intravenous immunoglobulin therapy. This treatment may improve the symptoms of anaemia, but it may precipitate a rash or arthropathy. Intravenous immunoglobulin G (IVIG) therapy has also been used in other cases of severe illnessFootnote 2Footnote 6Footnote 10.
PROPHYLAXIS: Pregnant women with sick children at home are advised to wash hands frequently and to avoid sharing eating utensilsFootnote 2. Isolation of infected persons is impractical, with the exception of hospitalized patientsFootnote 3. Health care workers should be advised of the importance of following good infection control measuresFootnote 2.
SECTION VI - LABORATORY HAZARDS
LABORATORY-ACQUIRED INFECTIONS: Many cases of laboratory-acquired infection have been reported, and occupational exposure to infectious aerosols in laboratories is suspected. Infectious aerosols can be generated by centrifugation, during the resuspension of virus pellets, or in washing stages of solid phase immunoassays. It is suggested that parvovirus infection will remain a problem in the laboratory unless the antigen is inactivated beforehand or, as a minimum precaution, aerosols are containedFootnote 12Footnote 13.
SOURCES/SPECIMENS: Parvovirus B19 has been found in blood (serum or plasma), respiratory secretions (e.g., saliva, sputum, or nasal mucus), bone marrow aspirates, cord blood samples, amniotic fluid cells and biopsy specimens of placenta, foetal tissues, synovial fluid, cells and tissue of affected joints, and skin tissue from systemic sclerosis that is used for B19 DNA detectionFootnote 4Footnote 6Footnote 10Footnote 22-Footnote 24.
SPECIAL HAZARDS: None.
SECTION VII - EXPOSURE CONTROLS / PERSONAL PROTECTION
RISK GROUP CLASSIFICATION: Risk Group 2Footnote 25.
CONTAINMENT REQUIREMENTS: Containment Level 2 facilities, equipment, and operational practices for work involving infected or potentially infected materials, animals, or cultures.
PROTECTIVE CLOTHING: Lab coat. Gloves when direct skin contact with infected materials or animals is unavoidable. Eye protection must be used where there is a known or potential risk of exposure to splashesFootnote 26.
OTHER PRECAUTIONS: All procedures that may produce aerosols, or involve high concentrations or large volumes should be conducted in a biological safety cabinet (BSC). The use of needles, syringes, and other sharp objects should be strictly limited. Additional precautions should be considered with work involving animals or large scale activitiesFootnote 26.
SECTION VIII - HANDLING AND STORAGE
SPILLS: Allow aerosols to settle and, while wearing protective clothing, gently cover the spill with paper towels and apply appropriate disinfectant starting at the perimeter, working inwards towards the centre. Allow sufficient contact time before clean upFootnote 26.
DISPOSAL: Decontaminate all materials for disposal by steam sterilisation, chemical disinfection, and incinerationFootnote 26.
STORAGE: In sealed containers that are appropriately labelledFootnote 26.
SECTION IX - REGULATORY AND OTHER INFORMATION
REGULATORY INFORMATION: The import, transport, and use of pathogens in Canada is regulated under many regulatory bodies, including the Public Health Agency of Canada, Health Canada, Canadian Food Inspection Agency, Environment Canada, and Transport Canada. Users are responsible for ensuring they are compliant with all relevant acts, regulations, guidelines, and standards.
UPDATED: November 2010.
PREPARED BY: Pathogen Regulation Directorate, Public Health Agency of Canada.
Although the information, opinions and recommendations contained in this Pathogen Safety Data Sheet are compiled from sources believed to be reliable, we accept no responsibility for the accuracy, sufficiency, or reliability or for any loss or injury resulting from the use of the information. Newly discovered hazards are frequent and this information may not be completely up to date.
Public Health Agency of Canada, 2010
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