Published Date: 2003-02-28 23:50:00
Subject: PRO/AH/EDR> Crimean-Congo hem. fever - Pakistan: suspected
Archive Number: 20030228.0498

CRIMEAN-CONGO HEMORRHAGIC FEVER - PAKISTAN: SUSPECTED
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Date: Fri 28 Feb 2003
From: Rashid A. Chotani <rchotani@jhsph.edu>
Source: Dawn newspaper online, Fri 29 Feb 2003 [edited]
<http://www.dawn.com/2003/02/26/local15.htm>

Pakistan: Suspected Crimean-Congo Hemorrhagic Fever Deaths in Rawalpindi
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2 brothers suspected to be suffering from Crimean-Congo Hemorrhagic Fever
(CCHF) died on Tue 25 Feb 2003 at the Holy Family Hospital. These deaths
occurred 5 days after a similar incident was reported from Rawalpindi
General Hospital. [Tragically] the dates coincided with the first
anniversaries of the deaths of 2 women, including a lady doctor, who died
of CCHF a year ago at the same hospital. The victims (3 and 5 years of age)
had come to the hospital on Tuesday at 2 am with high-grade fever and
epistaxis from Gawalmandi, a [densely] populated locality of the city.
Gawalmandi is mostly inhabited by lower-middle-class families and has
highly unhygienic environs. The area is administratively controlled by the
cantonment board. One of the boys died a few hours after arriving at the
hospital, while the other expired at around 10 am.
7 "close contacts", excluding the immediate relatives of the victims, have
been identified and isolated. The exact number of people under surveillance
is 16. The paediatric emergency ward and intensive care unit, where the 2
boys were kept for treatment, have been sealed and disinfected. Blood
samples of both the victims have been collected by National Institute of
Health, Islamabad and will be sent to South Africa for analysis. The
confirmation or otherwise of the disease can only be done after the report
from South Africa is received, and till then, these cases will continue to
be treated as suspected.
The 2 children had cared for and played with livestock prior to Eid-ul-Adha
(a Muslim holiday signifying sacrifice), and animals are sacrificed for 3
days. The holiday lasted from 12 to 14 Feb 2003. Thus, these children were
in close contact with the animals prior to the holiday and probably were
exposed to the tick _Hyalomma mirginatum_. The incubation period is around
2 to 7 days but has been reported to be as long as 12 days. In humans, the
disease appears suddenly with symptoms similar to those of influenza,
followed by a rash. Hemorrhage does not occur in all cases and can be more
severe in some, beginning on or about the fourth day and continuing for
about 2 weeks. The outbreak aggregate human case-fatality rate is around 30
percent.
In Pakistan, CCHF virus was first isolated in 1970 from ticks from the
Changa Manga forest, Lahore district, and from Hunza, Gilgit Agency. The
first reported case and the first nosocomial human case appeared in 1976,
when a laparotomy was performed on a patient with abdominal pain,
haematemesis, and melena. Since the first recognition of human cases, there
have been many outbreaks, of which only 2 have been reported in the form of
[referenced] publications.
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
haemorrhagic complications, and then exposed health care workers develop
the disease and often, the complications.
A mouse-brain vaccine is available in Europe and Russia, but it is not
known whether it is effective or safe in humans. Intravenous ribavirin has
been established as an effective antiviral therapy. Also oral ribavirin has
been shown to be effective in patients with less severe disease. The most
[effective] preventive measures are the use of repellents such as
diethyltoluamide and permethrin.
--
Rashid A. Chotani, MD, MPH
Department of Emergency Medicine
Department of International Health
Center for International Emergency Disaster & Refugee Studies
Director, Global Infectious Disease Surveillance & Alert System
The Johns Hopkins School of Medicine & Public Health
<rchotani@jhsph.edu>
[Crimean-Congo hemorrhagic fever virus (CCHFV), a member of the genus
_Nairovirus_ of the family _Bunyaviridae_ of segmented genome
negative-sense RNA viruses, is the cause of a zoonotic disease that for
many years was recognized only in Central Asia and eastern Europe. CCHFV is
known now to be present throughout Asia, the Middle East and Africa. In
recent years CCHFV-associated disease has been particularly prevalent in
countries bordering the Persian Gulf, where traditional sheep slaughtering
and butchering practices continue. The virus is maintained by a cycle
involving transovarial and transstadial transmission in _Hyaloma_ spp. and
related ticks. The larval and nymphal ticks become infected during feeding
on small mammals and birds, and the adults during feeding on wild and
domestic ruminants. Infection of wild and domestic ruminants results in
abundant production of CCHFV. Remarkably, there is no evidence of clinical
disease in animals other than humans, where the outcome can be a severe
hemorrhagic fever. - Mod.CP]

See Also

2002
----
Crimean-Congo hemorrhagic fever - Pakistan 20020228.3643
Crimean-Congo hemorrhagic fever - Pakistan (02) 20020313.3735
2001
----
Crimean-Congo hem. fever - Pakistan (Baluchistan) 20010531.1071
Crimean-Congo HF, confirmed - Pakistan (NW Frontier) 20010424.0800
Crimean-Congo HF, suspected - Pakistan (NW Frontier) 20010404.0674
Crimean-Congo HF, suspected - Pakistan (NW Front.)(02) 20010331.0652
Crimean-Congo HF - Afghanistan, Pakistan 20011004.2409
Crimean-Congo HF - Afghanistan, Pakistan (03) 20011011.2479
2000
----
Crimean-Congo hem. fever - Pakistan (Baluchistan) 20000925.1651
Crimean-Congo hem. fever - Pakistan (Baluchistan) (07) 20001122.2027
1998
----
Crimean-Congo hemorrhagic fever - Pakistan 19980509.0908
Crimean-Congo hemorrhagic fever - Pakistan: not? 19980902.1764
...................mpp/cp/pg/mpp

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