Waar komt hantavirus voor? Een wereldkaart van endemische regio's

Hantavirus infections have been reported on every inhabited continent. However, calling the whole world endemic would obscure what actually matters for risk assessment: the distribution is highly uneven, driven by where specific rodent reservoir species live, at what densities, and under what ecological conditions. This article maps the two main epidemiological worlds of hantavirus — the New World hantavirus pulmonary syndrome (HPS) belt and the Old World hemorrhagic fever with renal syndrome (HFRS) zone — and explains the notable outbreaks that have shaped our understanding of the disease.

1. New World: the Americas HPS belt

HPS-causing hantaviruses are distributed across North, Central, and South America. The risk is not uniform: it concentrates in rural, semi-arid, and forested areas where humans come into contact with rodent reservoirs.

United States and Canada

Sin Nombre virus (SNV) causes the majority of US HPS cases. The deer mouse (Peromyscus maniculatus) carries SNV across most of western North America, with the highest case concentration in the Four Corners region (Arizona, Colorado, New Mexico, Utah) and the broader US Southwest. The CDC has recorded over 850 confirmed HPS cases in the United States since 1993, with cases reported in 36 states. The US Southwest carries the highest per-capita risk among all US regions.

The Four Corners index cluster of 1993 — which identified HPS as a new syndrome — remains the most studied outbreak in the history of hantavirus epidemiology. It followed a wet spring that caused mast-fruiting of piñon pines, which in turn drove a peak in deer mouse populations.

Black Creek Canal virus (Florida), Bayou virus (Louisiana and Texas), Monongahela virus (eastern United States), and New York virus (northeastern United States) are additional New World strains that cause HPS at much lower frequencies than SNV.

Mexico, Central America, and Panama

HPS cases have been confirmed in Mexico and several Central American countries. Choclo virus causes HPS in Panama and has caused sporadic fatalities. The burden of disease in this region is likely underreported due to limited diagnostic capacity.

Chile and Argentina — highest ANDV risk

Andes virus is the dominant HPS strain in South America and the only hantavirus known to transmit from person to person. Chile and Argentina together account for the great majority of ANDV cases globally. The endemic corridor runs along the full length of Patagonia — from the Chilean lake district and the Nahuel Huapi basin in Argentina southward into Tierra del Fuego — and extends northward into the Andean foothills of both countries.

Notable Argentine outbreaks include the 1996 El Bolsón cluster, which first established person-to-person transmission for ANDV, and the 2018–19 Epuyén cluster in Chubut province, which involved 34 cases and confirmed sustained chains of household and healthcare worker transmission. Chile has experienced regular annual cases concentrated in the Araucanía, Los Lagos, and Aysén regions, where rural cabin stays and agricultural work create exposure opportunities.

The MV Hondius itinerary traversed Patagonian ports including Ushuaia (Argentina) and Punta Arenas (Chile) — both within the ANDV endemic zone — as well as remote fjord anchorages. Shore excursions in this environment provided exposure pathways for passengers and crew.

Brazil, Bolivia, Paraguay, Uruguay

Several distinct HPS-causing strains circulate in Brazil: Araraquara virus (São Paulo state, responsible for the highest fatality rate HPS cases recorded in South America — CFR above 40% in some series), Juquitiba, Castelo dos Sonhos, Laguna Negra (shared with Bolivia, Paraguay, and Argentina), and Anajatuba. Brazil has reported hundreds of HPS cases since the mid-1990s, with Araraquara virus driving notable clusters in rural São Paulo and Mato Grosso do Sul.

2. Old World: the Eurasia and Africa HFRS zone

HFRS is estimated to cause 150,000 to 200,000 hospitalisations per year globally. The vast majority occur in Asia, predominantly in China. The clinical severity varies dramatically by strain and country.

China — highest global HFRS burden

China bears by far the largest share of the global HFRS burden, reporting tens of thousands of confirmed cases per year. Hantaan virus (carried by the striped field mouse) and Seoul virus (carried by commensal rats) both circulate. The endemic regions include Heilongjiang, Jilin, Liaoning, Shaanxi, Shandong, and Hubei provinces. Spring and autumn peaks correspond to rice harvest and planting seasons, when farmers have intensive contact with field rodents.

Korea, Japan, and eastern Russia

South Korea has reported thousands of HFRS cases caused by Hantaan and Seoul viruses. The historical name hemorrhagic fever with renal syndrome derives partly from Korean War military cases, when thousands of US and UN soldiers were infected by Hantaan virus along the 38th parallel in the early 1950s — at the time an unidentified disease called "Korean hemorrhagic fever." Japan reports Seoul virus cases and a small number of cases caused by Hantaan-related strains in Hokkaido. Far Eastern Russia (Primorsky Krai, Khabarovsk) is part of the Hantaan endemic zone.

Scandinavia and northern Europe

Puumala virus, carried by the bank vole (Myodes glareolus), causes nephropathia epidemica (NE) — a form of HFRS that is generally milder than Hantaan or Dobrava disease. Finland has the highest reported incidence in Europe, with several thousand cases per year in epidemic years (following bank vole population peaks every 3–4 years). Sweden, Norway, and Russia also report substantial Puumala HFRS. NE cases are concentrated in rural areas where humans encounter vole habitat — farms, forests, and summer cottages. Urban cases are rare.

Central and southeastern Europe

Dobrava virus causes the most severe HFRS in Europe. It is carried by the yellow-necked mouse (Apodemus flavicollis) and has the highest case fatality of any European hantavirus — up to 12–15% in severe Dobrava genotype A cases. Significant outbreaks have been reported in the Balkans (Slovenia, Croatia, Bosnia and Herzegovina, Serbia, Kosovo), Greece, and Germany. Germany also reports Puumala cases, predominantly in southwest regions.

Russia — a continent-wide reservoir

Russia spans both the Puumala zone (western Russia and Siberia) and the Hantaan zone (far eastern Russia), making it one of the largest HFRS-endemic territories in the world. Western Russia and the Ural region report tens of thousands of Puumala cases in peak years. Total annual Russian HFRS cases have historically exceeded those reported by any other single European country.

Middle East, Africa, and Asia Minor

Seoul virus circulates wherever its commensal rat hosts are found, giving it a global distribution. Cases attributable to Seoul virus have been confirmed in Turkey, Iran, and several sub-Saharan African countries. Unique lineages of hantavirus have been identified in Africa — including the Tanganya virus in Tanzania and the Sangassou virus in Guinea — but systematic surveillance remains limited and the burden of HFRS from these African strains is poorly characterised.

3. Notable historical outbreaks

4. Travel risk: who is at risk and where

For the vast majority of international travellers — those who stay in hotels, travel urban itineraries, and do not engage with rural or wilderness environments — the risk of hantavirus infection is extremely low regardless of destination. The risk is concentrated in specific exposure scenarios:

• Sleeping in rural cabins, refugios, or huts in South America (particularly Patagonia and the Andean foothills of Chile and Argentina)
• Agricultural work, forestry, or field research in known endemic areas in Asia and Europe
• Camping in the US Southwest or other HPS-endemic North American regions, particularly in enclosed spaces or structures where deer mice may nest
• Wilderness trekking in rural Scandinavia or Central Europe during bank vole population peaks
• Any activity that involves disturbing rodent nesting material or closed, previously unoccupied structures in endemic areas

The MV Hondius outbreak is unusual in that it involved a ship-based exposure rather than a terrestrial rural setting, but the underlying mechanism — rodent access to an enclosed structure (the ship), contamination of surfaces, and close-quarters human habitation — is epidemiologically analogous to a contaminated cabin.

5. Surveillance gaps and underreporting

The global picture of hantavirus distribution is almost certainly incomplete. Countries with strong laboratory infrastructure and active surveillance — the United States, Chile, Argentina, Finland, Germany, South Korea — report cases regularly. Countries with limited diagnostic capacity, particularly in sub-Saharan Africa and parts of Southeast Asia and Latin America, likely harbour hantavirus transmission that goes undiagnosed because the clinical presentation resembles other febrile illnesses and specific testing is not routinely available.

The expanding range of the bank vole and commensal rat populations, combined with land-use changes that place humans closer to rodent habitat, make it likely that the reported burden underestimates the true global incidence. Enhanced sentinel surveillance in Africa and Southeast Asia is an identified priority in the WHO research agenda for hantaviruses.