Crimean-Congo hemorrhagic fever

Isolated male patient diagnosed with Crimean-Congo hemorrhagic fever

style="background:#Template:Taxobox colour;"|Crimean-Congo hemorrhagic fever virus
style="background:#Template:Taxobox colour;" | Virus classification
Group: Group V ((-)ssRNA) Family: Bunyaviridae Genus: Nairovirus Species: Crimean-Congo hemorrhagic fever virus

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Crimean-Congo hemorrhagic fever (CCHF) is a widespread tick-borne viral disease, a zoonosis of domestic animals and wild animals, that may affect humans. The pathogenic virus, especially common in East and West Africa, is a member of the Bunyaviridae family of RNA viruses. Clinical disease is rare in infected mammals, but commonly severe in infected humans, with a 30% mortality rate. Outbreaks of illness are usually attributable to handling infected animals or people.

Epidemiology

• Sporadic infection of people is usually caused by Hyalomma tick bite.
• Clusters of illness typically appear after people treat, butcher or eat infected livestock, particularly ruminants and ostriches.
• Outbreaks have occurred in clinical facilities where health workers have been exposed to infected blood and fomites.
• On July 28, 2005 authorities reported 41 cases of CCHF in Turkey's Yozgat Province, with one death.

Endemic Regions

• Endemic areas include Asia, Eastern Europe, the Middle East, a belt across central Africa and South Africa and Madagascar.
• Main environmental reservoir for the virus are small mammals (particularly European hare, Middle-African hedgehogs and multimammate rats).

Notable outbreaks

• During the summers of 1944 and 1945 over 200 cases of an acute, hemorrhagic, febrile illness occurred in Soviet troops rescuing the harvest following the ethnic cleansing of the Crimean Tatars.
• Virus was discovered in blood samples of patients and in the tick Hyalomma marginatum marginatum.
• Researchers soon recognized that a similar disease had been occurring in the Central Asian Republics.
• In 1969 analysis of a preserved blood sample collected from a febrile child in Zaire in 1956 showed the same virus.
• This finding gave rise to the present name of the disease.

History and Symptoms

• Typically, after a 1–3 day incubation period following a tick bite (5–6 days after exposure to infected blood or tissues), flu-like symptoms appear, which may resolve after one week.
• In up to 75% of cases, however, signs of hemorrhage appear within 3–5 days of the onset of illness: first mood instability, agitation, mental confusion and throat petechiae, then soon nosebleeds, bloody urine and vomiting, and black stools.
• The liver becomes swollen and painful.
• Disseminated intravascular coagulation may occur as well as acute kidney failure and shock, and sometimes acute respiratory distress syndrome.
• Patients usually begin to recover after 9–10 days from symptom onset, but 30% die in the second week of illness.

Laboratory diagnostics

• ELISA, RT-PCR, antibody titers, immunohistochemical staining, and virus isolation attempts are all laboratory tests to assist in the diagnosis of a potential Crimean-Congo hemorrhagic fever.
• An ELISA may be used for diagnosis during the acute phase of infection.
• Polymerase Chain Reaction may be used to identify viral RNA sequences in the blood or tissues collected.

Treatment

Treatment is primarily symptomatic and supportive, as there is no established specific treatment. Ribavirin is effective in vitro and has been used during outbreaks, but there is no trial evidence to support its use.

Risk Factors

Endemic Areas

• Travelling through endemic areas increase the risk of infection.
• Endemic areas include Asia, Eastern Europe, the Middle East, a belt across central Africa and South Africa and Madagascar.

Livestock

• Sheep, goats and cattle develop high titers of virus in blood, but tend not to fall ill.
• Transmission may occur through unprotected contact with blood and other body fluids of an infected animal.

Occupational

• The following individuals are at a higher risk of infection in endemic areas:
• Livestock workers
• Animal herders
• Slaughterhouse workers

Prevention

Limiting tick exposure

Tuck pants into socks

It is unreasonable to assume that a person can completely eliminate activities that may result in tick exposure. Therefore, prevention measures should emphasize personal protection when exposed to natural areas where ticks are present:

• Wear light-colored clothing which allows you to see ticks that are crawling on your clothing.
• Tuck your pants legs into your socks so that ticks cannot crawl up the inside of your pants legs.
• Apply repellents to discourage tick attachment. Repellents containing permethrin can be sprayed on boots and clothing, and will last for several days. Repellents containing DEET (n, n-diethyl-m-toluamide) can be applied to the skin, but will last only a few hours before reapplication is necessary. Use DEET with caution on children. Application of large amounts of DEET on children has been associated with adverse reactions.
• Conduct a body check upon return from potentially tick-infested areas by searching your entire body for ticks. Use a hand-held or full-length mirror to view all parts of your body. Remove any tick you find on your body.
• Parents should check their children for ticks, especially in the hair, when returning from potentially tick-infested areas.
• Ticks may also be carried into the household on clothing and pets and only attach later, so both should be examined carefully to exclude ticks.

Public health measures

• Where mammal and tick infection is common agricultural regulations require de-ticking farm animals before transportation or delivery for slaughter.
• Personal tick avoidance measures are recommended, such as use of insect repellents, adequate clothing and body inspection for adherent ticks.
• When feverish patients with evidence of bleeding require resuscitation or intensive care, body substance isolation precautions should be taken.
• The United States armed forces maintain special stocks of ribavirin to protect personnel deployed to Afghanistan and Iraq from CCHF.

External links

• Ergönül O. (2006). "Crimean-Congo haemorrhagic fever". Lancet Infect Dis. 6: 203–214. doi:10.1016/S1473-3099(06)70435-2.
• World Health Organization Fact Sheet

Gallery

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  Isolated male patient diagnosed with Crimean-Congo hemorrhagic fever (C-CHF). From Public Health Image Library (PHIL).

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  Cytoarchitectural changes found in a liver tissue specimen extracted from a Congo/Crimean hemorrhagic fever patient (280X mag). From Public Health Image Library (PHIL).

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  Cytoarchitectural changes found in a liver tissue specimen extracted from a Congo/Crimean hemorrhagic fever patient (400X mag). From Public Health Image Library (PHIL).