Review Article on Crimean Congo Virus Asghar Ali MPhil Public Health

Review Article on Crimean Congo Virus
Asghar Ali
MPhil Public Health & Clinical Microbiology
Supervisor Dr Syed Sadaf Akbar
Dadabhoy Institute of Higher Education (DIHE)
Department of Public Health Clinical Microbiology
Karachi, Pakistan
Email: [email protected]

Date: 28th April 2018

Crimean-Congo Hemorrhagic Fever Review Article in Pakistan
Asghar Ali and Dr Syed Sadaf Akbar
Email: [email protected]

Department of Public Health Microbiology, DIHE, Karachi, Pakistan
Crimean-Congo Hemorrhagic Fever (CCHF) is a tick born zoonotic and emerging disease in Pakistan caused by Nairovirus genus of Bunyaviradae Family. The Crimean –Congo Hemorrhagic Fever (CCHF) is the most widespread disease in the worldwide. It is high life threatening infection, its main vector ticks of the genus Hyalomma, the spread of this infected ticks into new. Which causes the spread of infection into unaffected areas. The Hyalomma ticks infest a wide spectrum of different wildlife species like a deer and hares, and free ranging livestock animals e.g. Goat, Cattle, and sheep, but many birds are resistant to this infection except Ostriches which is more susceptible to this infection. On the other hand which transmits from the infected animals to human beings through direct contact with infected animals and as well indirect to the blood and body fluid, and in the same way from the infected human to human transmission can occurs.

There is no vaccine available for this life threatening infection. Treatment is generally supportive including basic management of human intravenous fluids and blood products (platelets, fresh frozen plasma).early diagnosis and prompt management of the symptoms can result in a better clinical outcome. Antiviral Ribavirin now a days used by the number of country which have better result and as well as prophylactic treatment.

Crimean-Congo Hemorrhagic Fever is a big challenge for Public Health. In Pakistan at 2013 up till 30th September a total of 150 human samples have been received by the NIH for CCHF testing. Out of them 60 are positive while among them 12 patients had died (CFR 8%).
Key Words: CCHF- Crimean-Congo Hemorrhagic
Crimean-Congo Hemorrhagic Fever (CCHF) first occurred an epidemic in summer 1944, where 200 soviet military personal assisting in the war-devastated Crimean (chumakov1945) .it means that this disease had been known for many years previously. CCHF was first reported in Pakistan in 1976 but the number of cases has shown a dramatic rise since 2000 with 50-60 cases being reported annually. The incidence of CCHF peaks in June and October but cases occur throughout the year In Pakistan at 2012, DEWS received a total of 68 CCHF alert involving 141 suspected and 49 laboratory confirmed human cases resulting in 16 deaths (CFR: 33%), while during 2013 up till 30th September a total of 150 human samples have been received by the NIH for CCHF testing. Out of them 60 are positive while among them 12 patients had died (CFR 8%).

The main contributors for pathogenesis of CCHFV are endothelial cells and immune cells. Following lymphocytes, and hemophagocytosis are some of these tactics. The endothelial injury both leads to platelet aggregation and activation of the intrinsic coagulation pathway. The tissue factor releasing from the infected cells leads to developing of disseminated intravascular coagulation (DIC) by stimulating the extrinsic coagulation. The role of DIC is clear in pathogenesis

of the disease. In addition leukopenia, thrombocytopenia, anemia, prolonged prothrombin time (PT) and activated partial thrombo plastin time (APTT) and increased levels of fibrin degradation

Products, D-dimer, liver enzymes, and high CCHFV load are prominent in patients with severe CCHF.Postmortem histopathology examinations of liver biopsy specimens reveal necrotic foci
And massive necrosis. Cerebral hemorrhage, excessive anemia, dehydration and shock, myocardial infarction, pulmonary edema and pleural effusion were reported in fatal CCHF cases.
The CCHF virus is transmitted to people either by tick bites or through contact with infected animal blood or tissues during and immediately after slaughter. The majority of cases have occurred in people involved in the livestock industry, such as agricultural workers, slaughterhouse workers and veterinarians.
Human-to-human transmission can occur resulting from close contact with the blood, secretions, organs or other bodily fluids of infected persons. Hospital-acquired infections can also occur due to improper sterilization of medical equipment, reuse of needles and contamination of medical supplies.
Signs and Symptoms
The length of the incubation period depends on the mode of acquisition of the virus. Following infection by a tick bite, the incubation period is usually one to three days, with a maximum of nine days. The incubation period following contact with infected blood or tissues is usually five to six days, with a documented maximum of 13 days.

Onset of the symptoms is sudden, with fever, myalgia, (muscle ache), dizziness, neck pain and stiffness, backache, headache, sore eyes and photophobia (sensitivity to light). There may be nausea, vomiting, diarrhoea, abdominal pain and sore throat early on, followed by sharp mood swings and confusion. After two to four days, the agitation may be replaced by sleepiness, depression and lassitude, and the abdominal pain may localize to the upper right quadrant, with detectable hepatomegaly (liver enlargement).

Other clinical signs include tachycardia (fast heart rate), lymphadenopathy (enlarged lymph nodes), and a petechial rash (a rash caused by bleeding into the skin) on internal mucosal surfaces, such as in the mouth and throat, and on the skin. The petechiae may give way to larger rashes called ecchymosis, and other haemorrhagic phenomena. There is usually evidence of hepatitis, and
Severely ill patients may experience rapid kidney deterioration, sudden liver failure or pulmonary failure after the fifth day of illness.
The mortality rate from CCHF is approximately 30%, with death occurring in the second week of illness. In patients who recover, improvement generally begins on the ninth or tenth day after the onset of illness.
CCHF virus infection can be diagnosed by several different laboratory tests:
• enzyme-linked immunosorbent assay (ELISA) ;
• antigen detection;
• serum neutralization;
• reverse transcriptase polymerase chain reaction (RT-PCR) assay; and
• Virus isolation by cell culture.
Patients with fatal disease, as well as in patients in the first few days of illness, do not usually develop a measurable antibody response and so diagnosis in these individuals is achieved by virus or RNA detection in blood or tissue samples.

Investigations on patient samples present an extreme biohazard risk and should only be conducted under maximum biological containment conditions. However, if samples have been inactivated (e.g. with virucides, gamma rays, formaldehyde, heat, etc.), they can be manipulated in a basic biosafety environment
General supportive care with treatment of symptoms is the main approach to managing CCHF in people.
The antiviral drug ribavirin has been used to treat CCHF infection with apparent benefit. Both oral and intravenous formulations seem to be effective.
Prevention and Control
Controlling CCHF in animals and ticks

Ticks of the genus Hyalomma are the principal vector of Crimean-Congo haemorrhagic fever (Female is on top and male is below) Robert Swanepoel/NICD South Africa.It is difficult to

Prevent or control CCHF infection in animals and ticks as the tick-animal-tick cycle usually goes unnoticed and the infection in domestic animals is usually not apparent. Furthermore, the tick vectors are numerous and widespread, so tick control with acaricides (chemicals intended to kill ticks) is only a realistic option for well-managed livestock production facilities.
For example, following an outbreak at an ostrich abattoir in South Africa (noted above), measures were taken to ensure that ostriches remained tick free for 14 days in a quarantine station before slaughter. This decreased the risk for the animal to be infected during its slaughtering and prevented human infection for those in contact with the livestock.
There are no vaccines available for use in animals.
Reducing the risk of infection in people
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.
Public health advice should focus on several aspects.
? Reducing the risk of tick-to-human transmission:
? Wear protective clothing (long sleeves, long trousers);
? Wear light coloured clothing to allow easy detection of ticks on the clothes;

? Use approved ascaricides (chemicals intended to kill ticks) on clothing;
? Use approved repellent on the skin and clothing;
? Regularly examine clothing and skin for ticks; if found, remove them safely;
? Seek to eliminate or control tick infestations on animals or in stables and barns; and
? Avoid areas where ticks are abundant and seasons when they are most active.
? Reducing the risk of animal-to-human transmission:
? Wear gloves and other protective clothing while handling animals or their tissues in endemic areas, notably during slaughtering, butchering and culling procedures in slaughterhouses or at home;
? Quarantine animals before they enter slaughterhouses or routinely treat animals with pesticides two weeks prior to slaughter.
? Reducing the risk of human-to-human transmission in the community:
? Avoid close physical contact with CCHF-infected people;
? Wear gloves and protective equipment when taking care of ill people;
? Wash hands regularly after caring for or visiting ill people.
Controlling infection in health-care settings
Health-care workers caring for patients with suspected or confirmed CCHF, or handling specimens from them, should implement standard infection control precautions. These include

basic hand hygiene, use of personal protective equipment, safe injection practices and safe burial practices.
As a precautionary measure, health-care workers caring for patients immediately outside the CCHF outbreak area should also implement standard infection control precautions.
Samples taken from people with suspected CCHF should be handled by trained staff working in suitably equipped laboratories.
Recommendations for infection control while providing care to patients with suspected or confirmed Crimean-Congo haemorrhagic fever should follow those developed by WHO for Ebola and Marburg haemorrhagic fever.
WHO response
WHO is working with partners to support CCHF surveillance, diagnostic capacity and outbreak response activities in Europe, the Middle East, Asia and Africa.
WHO also provides documentation to help disease investigation and control, and has created an aide–memoire on standard precautions in health care, which is intended to reduce the risk of transmission of blood borne and other pathogens.