CCHF for Holy Family Hospital 2nd November 2010

Crimean Congo Hemorrhagic Fever: 

Crimean Congo Hemorrhagic Fever Holy Family Hospital Rawalpindi-Pakistan Dr. Jawad Mofleh Temporary Advisor WHO, Pakistan November 2, 2010 MOFLEHJ@pak.emro.who.int or jmofleh@yahoo.com

Outlines : 

Outlines Background History of CCHF Virus Ticks Disease- Signs and Symptoms etc Diagnosis Treatment

Viral Hemorrhagic Fevers: 

Viral Hemorrhagic Fevers Viral Hemorrhagic Fevers (VHFs) animal & human diseases Five distinct families of RNA viruses: Arenaviridae e.g. Lass Fever Bunyaviridae e.g. CCHF Filoviridae e.g. Ebola Flaviviridae e.g. Dengue Fever Togaviridae e.g. Equine Encephalitis Characterized by fever & bleeding All can progress to high fever, shock and death

Crimean Congo Hemorrhagic Fever: 

Crimean Congo Hemorrhagic Fever Zoonotic- tick born disease 1944 Crimea (Ukraine) 1956 Congo 1969 it is found that Crimea and Congo disease was the same Spread and extend affected by climatic change Range of the virus is extending

History of Disease in Region: 

History of Disease in Region 1953-1968: Epidemics occurred in Astrakhan 1963-1971: Rostov Oblasts of USSR 1976:outbreaks in Pakistan and numerous lesser outbreaks in southern USSR Source: Journal of Medical Entomology, Volume 15, Number 4, 22 May 1979 , pp. 307-417(111)

History of disease in region: 

History of disease in region 1978: Tracked down in Khorasan-Iran Reported that virus entered through imported cattle from eastern borders Source: http://english.peopledaily.com.cn/200206/21/eng20020621_98278.shtml

History of Disease in Pakistan: 

History of Disease in Pakistan 1970 :The virus was first isolated from ticks from the Changa Manga forest, Lahore district, and of Hunza, Gilgit Agency 1976: The first reported case and the first nosocomial human case occurred when a laparotomy was performed on a patient with abdominal pain, haematemesis and melena. Source: NIH Presentation on CCHF 2004

History of Disease in region: 

History of Disease in region Official had earlier rejected reports that 30% of Iran's cattle were contaminated with CCHF, stressing that results of medical samples taken from smuggled cattle from Afghanistan, where the disease originated from, had indicated 1.6% contamination (June 2002) Source:http://english.peopledaily.com.cn/200206/21/eng20020621_98278.shtml

Geographical Distribution: 

Geographical Distribution

Slide 10: 

Casual agent Nairovirus of bunyaviridea Seasonal: temperate climates from June to September Reservoirs: hares, some birds, Hyalomma species of ticks Sheep, cattle, camels and other mammals are hosts Domestic animals are amplifying agents The virus

Slide 11: 

Incubation period: tick bite 1-3 days, maximum 9 days contact with infected blood and tissue of animals 3-5 days, maximum 13 days Case Fatality Rate: 2-50%, occurring between days 5-14 of illness Highest case fatality rates UAE 1994-95 (73%) China(80%) Epidemiology

Epidemiology ….: 

Epidemiology …. Transmission: Tick bite( H. Marginatum, H. anatolicum) Nasocomial infections Direct contact with contaminated blood or other body fluids (during slaughtering) Susceptibility: Immunity after infection (maybe life long)

Hyalomma Tick-1: 

Hyalomma Tick-1

Ticks -2: 

Ticks -2 Distribution of CCHFV coincides distribution of Hyalomma ticks Larvae and nymphs feeds on small mammals(e.g. hare ,birds) Adult ticks prefer large animals

Where do CCHF viruses live?: 

Where do CCHF viruses live? Mainly ticks Virus is transmitted from infected female ticks to its eggs Animals infected from bite of infected ticks Cattle and sheep are viremic for about one week but are asymptomatic Many birds are resistant to infection, but ostriches are susceptible

Survival of Tick depends on:: 

Survival of Tick depends on: Abandoned Slopes with periodic rain Good vegetational Cover Ample hosts Increased tick attack rate seen agricultural / livestock development in new area large-scale movement of population into new area

Disease in Human: 

Disease in Human

Signs and Symptoms: 

Signs and Symptoms Sadden onset headache high fever back pain joint pain stomach pain vomiting Red eyes flushed face red throat Petechiae Jaundice Echymoses Nose & gum bleeding- etc Injection site bleeding Begins on 4th day of illness and last about 2 wks.

CASE DEFINITION: 

CASE DEFINITION Suspected Case Patient with sudden onset of illness with high-grade fever over 38.5degC for more than 72 hrs and less than 10 days, especially in CCHF endemic area and among those in contact with sheep or other livestock (shepherds, butchers, and animal handlers) Probable case Suspected case, AND Thrombocytopenia less than 50,000/mm3 AND any two of the following: Petechial or purpuric rash, Epistaxis, Haematemesis, Haemoptysis, Blood in stools, Ecchymosis, Gum bleeding, Other haemorrhagic symptom AND No known predisposing host factors for haemorrhagic manifestations

Con..: 

Con.. Confirmed case Probable case with positive diagnosis of CCHF in blood sample, Confirmation of presence of IgG or IgM antibodies in serum by ELISA Detection of viral nucleic acid in specimen by PCR Isolation of virus

Lab Diagnosis: 

Lab Diagnosis Virus culture, blood or tissue PCR ELISA Other tests

Slide 24: 

Ergonul O. Lancet ID 2006; 6: 203-214 PLTs Incubation 3-7 days Prehemorrhagic period 1-7 days Hemorrhagic period 2-3 days Convelescence Bleeding (hematemesis, melena, etc.) somnolence AST ALT WBCs Fatality happens Polymerase Chain Reaction: The first 9 days Myalgia, Fever, Nausea-vomiting Diarrhea 7 d 10 d days DIC IgM (7 days-4 mo) IgG (7 days-5 years) viremia The Clinical Course of Crimean-Congo Hemorrhagic Fever

Lab diagnosis, cont’d: 

Lab diagnosis, cont’d Fatal cases may not develop antibody Diagnosis of Fatal Cases: Virus isolation from blood or tissue grown in cell culture Identification of viral antigens in tissue samples Detecting the viral genome through the polymerase chain reaction (PCR)

TREATMENT: 

TREATMENT General supportive therapy volume and blood component replacement Ribavirin Therapy

Slide 30: 

PLTs Incubation 3-7 days Prehemorrhagic period 1-7 days Hemorrhagic period 2-3 days Convelescence AST and ALT Fatality 7 d 10 d days Disseminated Intravascular Coagulation viremia EARLY PHASE LATE PHASE Ribavirin could be more effective in early phase CYTOKINES Ergonul O. Treatment of CCHF, Antivir Res 2008 The Role of Ribavirin in CCHF

RIBAVARIN TREATMENT /PROPHYLAXIS: 

RIBAVARIN TREATMENT /PROPHYLAXIS High-dose oral ribavarin treatment and prophylaxis constitutes the following: 2 gm loading dose 4 gm/day in 4 divided doses for 4 days 2 gm/day in 4 divided doses for 6 days = 30 gm Use under supervision of knowledgeable physician.

Adverse Effects of Ribavirin: 

Adverse Effects of Ribavirin Teratogenic with 12 day half-life Eye irritation Throat irritation Headache nausea fatigue rhinitis. Hemolytic anemia Leukopenia Depression Bronchospasm pulmonary dysfunction elevated ALT

References: 

References USAMRIID’s Medical Management Of Biological Causalities Handbook, 5th Edition, August 2004, FORT DETRICK FREDERICK, MARYLAND NIH Presentation on CCHF in Pakistan 2004 Dr. Jawad Mofleh, Overview of CCHF, May 2010, Regional Emerging Infectious Disease, Dushanbe Tajikistan Dr. Jawad Mofleh, Outbreak of CCHF in Western Region of Afghanistan, 2008, International Public Health Conference, Safi Landmark Kabul Afghanistan- 2008 Dr. Zarif Akbarian, outbreak of CCHF in Herat province ,2008 Disease Early Warning System, Case Definitions and Standard Procedures for collection and Transportation of Human Disease Samples include prevention and Control measures August 2009-Pakistan Control of Communicable Disease Manual David L. Heymen, MD , Editor, Nineteen Edition 2008 Ergonul O. Lancet ID 2006; 6: 203-214 Crimean Congo Hemorrhagic Fever, A Global Perspective, by Onder Erganul and Chirs A. whitehous, 2007 Springer

Thank you: 

Thank you

Clinical Feature: 

Clinical Feature Photo by Dr. Zarif Akbarian, DEWS Officer, Western Region Afghanistan

Massive Bleeding from the incision site: 

Massive Bleeding from the incision site Courtesy Dr. Zarif Akbarian, DEWS Officer, Western Region Afghanistan

Slide 37: 

Photo by Dr. Zarif Akbarian, DEWS Officer, Western Region Afghanistan Injection Site Echymoses

WHO SHOULD RECEIVE PROPHYLAXIS WITH RIBAVIRIN?: 

WHO SHOULD RECEIVE PROPHYLAXIS WITH RIBAVIRIN? 1)Those who have direct percutaneous contact (e.g. sharp injury) with body fluids of probable or confirmed CCHF case. 2)Those who have come into contact with the body fluids of cases, and during a monitoring period of 14 days after last exposure during which temperature is taken twice a day, develop high fever, headache and myalgia.

Standard Infection precautions while emerging VHF : 

Standard Infection precautions while emerging VHF Use Standard Precautions with All Patients Identify Suspected Cases of VHF Isolate the Patient Wear Protective Clothing Disinfect Reusable Supplies and Equipment Use Safe Burial Practices Mobilize Community Resources and Conduct Community Education Make Advance Preparations to Use VHF Isolation Precautions