crimean-congo hemorrhagic fever (cchf)

CRIMEAN-CONGO HEMORRHAGIC FEVER

JIBRAN MOHSINRESIDENT, SURGICAL UNIT I

SIMS/SERVICES HOSPITAL, LAHORE

OUTLINE• HISTORY

• PROBLEM STATEMENT

• EPIDEMIOLOGICAL DETERMINANTS• Agent factors• Host factors• Environmental factors• Mode of transmission• Incubation period

• CASE DEFINITIONS

• NATURAL HISTORY

• TREATMENT PROTOCOL

• PREVENTION AND CONTROL

• PROPHYLAXIS

• SUMMARY

HISTORY

• Etymology:

• Disease 1st described in Crimea in 1944.• Virus 1st Identified in Congo in 1956.

PROBLEM STATEMENT

• Mortality rate 2 % to 50 %

• ALERT THRESHOLD:• 1 probable case is an alert requires an immediate investigation.

• OUTBREAK THRESHOLD:• 1 confirmed case of CCHF is an outbreak

PROBLEM STATEMENT

• Endemic in Pakistan with sporadic outbreaks

• 1st case reported in 1976

• Since 2000 dramatic rise in number of cases (50-60 cases/year)

• Incidence peaks in June and October BUT cases occur throughout the year.

• From 2011 to 2014 total 280 confirmed cases.

PROBLEM STATEMENT

• Exposure of bulk of cases was traced back to animals in Quetta, Zhob, Killa Saifullah, Killa Abdullah, Pishin, Loralai and Mua Khel districts of Balochistan

• Similarly a number of patients diagnosed in Karachi, Rawalpindi, Multan, D.I Khan, Mansehra, Peshawar, Landi Kotal and Abbottabad(recently) H/O contact and slaughtering animals.

• Imported cases from Afghanistan are continuously being reported to major hospitals of Peshawar, Quetta and Islamabad throughout the year.

PROBLEM STATEMENT

TREND IN PUNJAB (PAKISTAN)YEAR SUSPECTED CASES CONFIRMED CASES DEATHS2012 8 5 32013 18 9 52014 27 10 52015 47 7 32016 13 3 2

ACCORDING to a MEDIA REPORT (20-AUG-2016), total 18 deaths has occurred till now in 2016 (5 deaths in Karachi, 11 in Quetta and 2 in

Bahawalpur)

PROBLEM STATEMENT

• Last death reported on 20-AUG-2016

EPIDEMIOLOGICAL DETERMINANTS(AGENT FACTORS)

• Infectious Agent:

• CCHF virus Nairovirus genus of Bunyaviridae family

• -ssRNA virus

EPIDEMIOLOGICAL DETERMINANTS(HOST FACTORS)

• Reservoir hosts hares and birds and Hyalomma ticks

• Amplifying hosts Domestic animals (sheep, goats and cattle)

EPIDEMIOLOGICAL DETERMINANTS(HOST FACTORS)

• HUMANS AT RISK

• Shepherds, • Butchers, • Animals handlers, • Tick handlers,• Agricultural workers, • Veterinarians,• Health workers (including doctors-surgeons)• Migrating people along with their animals e.g. Afghan refugees, IDPs and nomadics

• higher probability of susceptible animals being bitten by infected ticks• increase risk of transmission to humans during handling)

EPIDEMIOLOGICAL DETERMINANTS(ENVIRONMENTAL FACTORS)

• SEASONALITY:

• Peak during Fall and Spring seasons; associated with • life-cycle of ticks, • exposure of newborn animals, • exposure of migrating animals, and • human contact with viremic animals during slaughter and ticks during

handling

EPIDEMIOLOGICAL DETERMINANTS(MODE OF TRANSMISSION)

• 3 modes of transmission:

• Bite or handling adult infected Hyalomma tick (vector) ; (Tick –human) OR

• Direct contact with blood/tissue of infected domestic animals (slaughtering/butchering); (animal-human) OR

• Direct contact with blood/tissue of infected patients (e.g. nosocomial infections are common) (human-human)

EPIDEMIOLOGICAL DETERMINANTS(INCUBATION PERIOD)

• INCUBATION PERIOD:

• Usually 1-3 days after tick bite (max. 9 days)

• 5-6 days after exposure to infected blood or tissues (max. 13 days)

CASE DEFINITIONS• Sudden onset illness, high grade fever (≥ 38.50C or 101.30F) for > 72 hrs and < 10 days

AND

• Any of the following symptoms• Myalgia, backache• Headache, neck pain, neck stiffness, dizziness• Sharp mood swings, agitation, confusion, depression, sleepiness and lassitude• Photophobia, sore eyes• Sore throat• Nausea, vomiting, diarrhea and abdominal pain• Ecchymosis, mucosal bleed• Lymphadenopathy AND

• Any 1 or more• Contact with live stock and live stock handlers (Shephreds, butchers)• Endemic area (any patient from Balochistan. KPK, Sindh-Balochistan border, KPK-Punjab

Border)• 14 days before and 14 days after Eid-ul-Azha• Health care worker & VeterinariansSU

SPEC

TED

CASE

NB: fever does not respond to antibiotics or anti-malarial treatment.

CASE DEFINITIONS• Suspected case with acute history of febrile illness 10 days or less, AND

• Thrombocytopenia < 50,000/mm3 AND

• Any 2 of the following:• Petechial or purpuric rash, • epistaxis, • hematemesis, • hemoptysis, • blood in stools, • ecchymosis, • gum bleed or• other hemorrhagic manifestation AND

• No known predisposing host factors for hemorrhagic manifestationsPR

OBAB

LE

CASE

CASE DEFINITIONS

• Probable case with positive diagnosis of CCCHF in blood sample (performed in specially equipped high biosafety level laboratories

• Positive diagnosis includes any of the following:• ELISA (IgM & IgG)• PCRCO

NFIR

MED

CA

SE

NATURAL HISTORY

NATURAL HISTORY

• Death occurs in 2nd week of illness. • Recovery starts on 9th or 10th day of onset of illness.

• Complications: (after 5th day)• Hepatitis (tender hepatomegaly)• rapid kidney deterioration, • sudden liver failure or • pulmonary failure• DIC

TREATMENT PROTOCOL

• General supportive therapy is the mainstay of patient management in CCHF.

• Intensive monitoring to guide volume and blood component replacement.

• Probable case: • Oral Ribavirin : 2 gram loading dose• 4 g/day in divided doses (8 hourly) for 6 days• 2 g/day in divided doses for 6 days

NB: Pregnancy should be absolutely prevented (whether female or male partner is victim) within 6 months of completing a course of Ribavirin.

PREVENTION AND CONTROL

• Hospitals and Health facilities• Measures to reduce the risk of human-to-human (NOSOCOMIAL) transmission.

• Public Education • Measures to reduce the risk of tick-to-human transmission.

• Measures to reduce the risk of animal-to-human transmission.

HUMAN-TO-HUMAN (NOSOCOMIAL) TRANSMISSION

• Biosafety is key to avoid nosocomial infection.

• Isolation of patient (barrier nursing techniques)

• Standard infection control precautions• Personal protective equipment, • Basic hand hygiene, • Safe injection practices,• Safe sampling and • Safe burial practices.


• Isolation of patient (barrier nursing techniques)

• Isolation of probable and confirmed CCHF cases in separate room

• Only designated medical/para-medical staff and attendants should attend the patient.

• All medical and para-medical staff and attendants should wear PPE on entering and remove on exiting room.


• All secretions of the patient and hospital clothing in use of the patient and attendants should be treated as infectious and, where possible, should be autoclaved before incinerating.

• Disposable articles should be completely incinerated

• Gown should be autoclaved before sending to laundry or incineration


• All instruments should be decontaminated and autoclaved before re-use.

• All surfaces should be decontaminated with liquid bleach.

• After the patient is discharged, room surfaces should be wiped down with liquid bleach to kill virus, and the room should be fumigated if risk of tick infestation.


• All used material e.g. syringes, gloves, cannula, tubing etc. should be collected in autoclavable bag and autoclaved before incinerating.


• PPE (Personal Protective Equipment)• Disposable mask• Disposable gown• Disposable gloves• Goggles


• BASIC HAND HYGIENE• wash hands regularly after caring for or visiting ill people.

• SAFE INJECTION PRACTICES• Avoid spills, pricks, injury and accidents during the management of patient.

• Needles should not be re-capped but discarded in proper safety disposal box.


• SAFE SAMPLING

• Samples for laboratory testing should be properly collected, labelled, sealed, and

• decontaminated from outside with liquid bleach and packed in triple container packing

• Designated laboratory should be informed about the sample and should be transported to the designated laboratory with great caution, ensuring there would be no breakage or spills.


• SAFE BURIAL PRACTICES

• Thick and long rubber gloves or double pair of surgical gloves should be used for washing the body for burial.

• The dead body should be sprayed with 1:10 liquid bleach solution and then wrapped in the winding sheet.

• The winding sheet should be sprayed with bleach solution.• It should then be placed in a plastic bag, which should be sealed with adhesive tape. • Disinfect the transport vehicle• Burn all clothing of the deceased.

PUBLIC EDUCATION

TICK-TO-HUMAN TRANSMISSION

• Tick control with acaricide (chemicals intended to kill ticks) is a realistic option for well-managed livestock production facilities. • Animal dipping in an insecticide solution is recommended.

• Public should avoid tick-infested areas when feasible especially when ticks are active (spring to fall).

TICK-TO-HUMAN TRANSMISSION

• To minimize exposure,

• wear light (for easy identification of tick) clothing that covers legs and arms,

• tuck pants into socks,

• Regularly examine clothing and skin for ticks and

• Apply tick repellent such as diethyltoluamide (Deet®, Autan®) to skin or permethrin (a repellent and contact acaricide) to pant legs and sleeves.

ANIMAL-TO-HUMAN TRANSMISSION

• Persons who work with livestock or other animals in the endemic areas should take practical measures to protect themselves. (notably during slaughtering, butchering and culling procedures in slaughterhouses or at home, agricultural workers and veterinarians)

• Use of repellents on skin (e.g. DEET) and

• Clothing (e.g. Permethrin)

• Wearing gloves or other protective clothing to prevent skin contact with infected tissues or blood.

PROPHYLAXIS – DEFINITION OF “CONTACT”

CASE I1. Health workers who experienced

accidental needle stick injury or other accident where blood or secretions of patient were in direct contact with open wound or mucous membrane. e.g.

• surgeons operating on probable or confirmed cases (blood spillage over open wound over exposed area or eyes of surgeons, needle prick) or

• House officer/lab technician taking sample of patient or

• Ward boy emptying the NG, Foley and drain bags

• Nurse giving medication to patient

CASE II1. People who were exposed to same

animal(s) as the patient.

2. Members of the patient’s family or who were exposed to the patient.

3. Health workers who were exposed to sick patient, i.e. while physically examining or treating the patient.• Non-operating consultants doing ward

round• Non-operating HO/PGR looking after

patient• Ward boy, Nurse, Lab technician

PROPHYLAXIS PROTOCOL

• CASE I

• Do baseline blood studies directly after the accident and

• then start the person on the ribavirin protocol in consultation with physician.


• CASE II

• Monitored for 14 days (max) from date of last contact with patient or other source of infection

• Record temperature twice daily

• If temperature ≥ 38.50C , headache and muscle pains, he/she would be considered a probable case and should be admitted to hospital, send baseline blood tests and started ribavirin treatment.


• No point in testing the blood for CCHF confirmation during the 1st 14 days after contact unless they are genuinely sick

• Obtain blood tests to confirm CCHF only when contact gets definitely sick during the monitoring period (14 days)• Increased body temperature ≥ 38.50C• Headache and myalgia.

• After 14 days observation period, one may consider testing blood of contact for research purposes , to confirm whether they did or did not undergo sub-clinical infection.


• If confirmed case

• Prophylaxis to all the close contacts (3 feet close to patient)

• Ribavirin 400 mg 12 hourly for 5 days

VACCINATION

• Although an inactivated, mouse brain-derived vaccine against CCHF has been developed and used on a small scale in eastern Europe, there is currently no safe and effective vaccine widely available for human use.

• In the absence of a vaccine, the only way to reduce infection in people is by raising awareness of the risk factors and educating people about the measures they can take to reduce exposure to the virus.

WHAT TO DO ON EID-UL-AZHA?• Take precautions while going to buy animal• Precautions should also be taken by people selling animals• Site of selling animals must not be in residential area• Animal should be treated with acaricide• Avoid direct contact (touching with bare hands) with animal and person selling and slaughtering animal• Person slaughtering animal should take precautions• Avoid open spillage of blood of animal over floor• Proper disposal of non useable tissue of animal in plastic bag• Infected meat should be avoided??

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crimean-congo hemorrhagic fever (cchf)

Health & Medicine