Published Date: 2002-02-28 23:50:00
Subject: PRO/AH/EDR> Crimean-Congo hemorrhagic fever - Pakistan
Archive Number: 20020228.3643

CRIMEAN-CONGO HEMORRHAGIC FEVER - PAKISTAN
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See Also

2001
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Crimean-Congo hem. fever - Pakistan (Baluchistan) 20010531.1071
2000
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Crimean-Congo hem. fever - Pakistan (Baluchistan) (07) 20001122.2027
Crimean-Congo hem. fever - Pakistan (Baluchistan) 20000925.1651
1998
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Crimean-Congo hemorrhagic fever - Pakistan: not? 19980902.1764
Crimean-Congo HF, nosocomial - Pakistan, 1994 19980811.1581
Crimean-Congo hemorrhagic fever - Pakistan 19980509.0908
Date: Tue 26 Feb 2002
From: Rashid Chotani <rchotani@jhsph.edu> [edited
Crimean-Congo hemorrhagic fever in Pakistan
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As of Mon 25 Feb 2002, 3 deaths at Holy Family Hospital, Rawalpindi,
Pakistan have been suspected to be due to Crimean-Congo hemorrhagic fever
(CCHF). One of the casualties was a female physician who contracted the
disease in the hospital while taking care of a female patient brought in
from Azad Kashmir with hemorrhage.
The female physician developed fever, bleeding diathesis, and drowsiness on
Mon 18 Feb 2002. She was given intravenous antiviral medication and
ventilator support, but developed uncontrolled hemorrhage from multiple
sites and died. Blood samples from her have been sent to South Africa. So
far 2 other physicians who treated the female physician have been reported
to have developed symptoms of the disease. Around 60 contacts have been
identified, including 3 doctors and 2 nurses. They are being monitored
closely; around 15 are on antiviral therapy.
In 2000 and 2001 about 115 viral hemorrhagic fever case have been reported
from Baluchistan and Northwest Frontier Province (to NIH Pakistan), out of
which between 34 and 39 deaths have occurred due to bleeding and other
complications.
The [virus responsible for this hemorrhagic fever was first described by
Russian scientists in the Crimea in 1944 and was given the name Crimean
hemorrhagic fever virus (1). It was established that disease in humans was
associated with the bite of the tick _Hyalomma mirginatum_. A similar
illness was identified in the Congo in 1956. Subsequently, it was shown
that the Congo virus was identical to the Crimean virus and in 1969 this
illness was renamed as Crimean-Congo hemorrhagic fever (CCHF). CCHF virus
is distributed widely throughout arid regions of Africa, Eastern Europe,
and Asia and causes a severe hemorrhagic fever (2).
The virus was isolated from ticks in the Changa Manga forest, Lahore
district, and of Hunza, Gilgit Agency in Pakistan and reported in 1970 (3).
The first reported case [of human disease in Pakistan was reported in 1976
when a laparotomy was performed on a patient with abdominal pain,
hematemesis, and melaena (4). Since the first recognition of human cases
there have been multiple outbreaks of which only a few have been reported
in publications. For example, in 1987 a surgeon in Rawalpindi operated on a
patient from Quetta and subsequently died; 2 other operating assistants who
were also infected recovered, one of whom was later shown to have antibody
to CCHF virus. Epidemiological studies of viral hemorrhagic fevers indicate
that airborne transmission from person to person is unusual (5-7). The
risks associated with various other modes of transmission are not well
defined because most care-givers who acquired infection have multiple
contacts through multiple modes (8).
Nosocomial outbreaks in Pakistan continue despite dissemination of
information on preventive measures among medical staff. These outbreaks
follow a pattern. The index case always dies, succumbing to severe
hemorrhagic complications and then exposed health care workers develop the
disease and often, the complications.
References:
(1) Leshchinskaya EV. Clinical picture of Crimean haemorrhagic fever (in
Russian). Trudy Inst Polio Virus Entsef Akad Nauk SSSR 1965; 7: 226-36.
(2) Hoogstral H. The epidemiology of tickborne Crimean-Congo haemorrhagic
fever in Asia, Europe and Africa, Journal Med Entomol 1979; 15: 307-417.
(3) Begum F, Wisseman CL, Casals J. Tickborne viruses of Pakistan. Viruses
similar to, or identical with, Crimean haemorrhagic fever (Congo-Semunya),
Wad Medani and Pak Argas 461 isolated from ticks of the Changa Manga
forest, Lahore district, and of Hunza, Gilgit Agency, Pakistan. Am J
Epidemiol 1970; 92: 197-202.
(4) Burney MI, Ghafoor A, Saleem M, Webb PA, Casals J. Nosocomial outbreak
of viral hemorrhagic fever caused by Crimean Congo hemorrhagic fever virus
in Pakistan. Am J Trop Med Hyg 1976; 29: 941-37.
(5) Baron RC, McCormick JB, Zubair OA. Ebola virus disease in Southern
Sudan: hospital dissemination and intrafamiliar spread. Bull World Health
Organ 1983; 6: 997-1003.
(6) CDC. Management of patients with suspected viral hemorrhagic fever.
MMWR Morb Mortal Wkly Rep 1988; 37: 1-15.
(7) Fisher-Hoch SP. Stringent precautions are not advisable when caring for
patients with viral haemorrhagic fevers. Reviews in Medical Virology 1993;
3: 7-13.
(8) CDC. Update: Management of patients with suspected viral hemorrhagic
fever, United States. MMWR Morb Mortal Wkly Rep 1995; 44: 475-9.
--
Rashid A Chotani, MD MPH
Assistant Professor & Director
Global Infectious Diseases Surveillance & Alert System [GIDSAS
Center for International Emergency, Disaster and Refugee Studies
The Johns Hopkins School of Medicine & Public Health
615 North Wolfe Street, E-8139
Baltimore, MD 21205
<rchotani@jhsph.edu>
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