Epidemic Investigation Cell (EIC) Public Health Laboratories Division National Institute of Health, Islamabad, Pa istan !

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/uidelines for 0anagement, Prevention and Control of Crimean&Congo Hemorrhagic +ever (CCH+)
November (##1
Crimean Congo Haemorrhagic Fever (CCHF) is a viral haemorrhagic fever caused by the Nairovirus of the Bunyaviridae family, transmitted to humans by the bite of the Hyalomma tick or by direct contact with blood of an infected animal or human. CCHF is a severe disease with a high case fatality rate ranging from ! to "#!. $he disease was first described in Crimea in %&'' and identified in %&"( in Congo and thus develo)ed the current name for the disease and its causative virus.%

Geographical distribution and trend of CCHF in Pakistan

CCHF was first re)orted in *akistan in %&+( but the number of cases has shown a dramatic rise since ### with "#,(# cases being re)orted annually. -hile Balochistan and N-F* )rovinces are the most affected areas, one case has been re)orted from ./ad 0ammu and 1ashmir in ##2, and in ##' one case has been re)orted from .ttock 3istrict of *un4ab *rovince. 5n 7r *akistan, the incidence of CCHF )eaks in 0une and a)h,% :easonal occurrence of CCHF in 6ctober but cases occur throughout the year (7ra)h,%).
*akistan.

Reservoirs, hosts, transmission, and incubation:

8eservoir hosts are believed to be hares, birds and Hyalomma ticks. 3omestic animals (shee), goats and cattle) act as am)lifying hosts. 5n *akistan, CCHF is transmitted from the adult tick (Hyalomma genus), direct contact with the blood 9 tissue of infected domestic animals (e.g. butchering), or direct contact with the blood 9 tissue of infected )eo)le (e.g. nosocomial). *o)ulation migration with animals contributes to the higher )robability of susce)tible animals being bitten by infected ticks, thus increasing the risk of transmission to humans who handle the animals.2 !he incubation period after tic bite is usuall2 % to ) da2s, 3ith a ma,imum of ' da2s. !he incubation period follo3ing contact 3ith infected blood or tissues is usuall2 $ to 4 da2s, 3ith a documented ma,imum of %) da2s. 1

Case definition
Suspected Case
*atient with sudden onset of illness with high,grade fever over 2;." C for more than + hrs and less than %# days, es)ecially in CCHF endemic area and among those in contact with shee) or other livestock (she)herds, butchers, and animal handlers). Note that fever is usually associated with headache and muscle )ains and does not res)ond to antibiotic or anti, malarial treatment.

Probable case
:us)ected case with acute history of febrile illness %# days or less, 5ND $hrombocyto)enia less than "#,###9mm2 5ND any two of the following< *etechial or )ur)uric rash, =)ista>is, Haematemesis, Haemo)tysis, Blood in stools, =cchymosis, 7um bleeding, 6ther haemorrhagic sym)tom 5ND No known )redis)osing host factors for haemorrhagic manifestations"

Confirmed case
*robable case with )ositive diagnosis of CCHF in blood sam)le, )erformed in s)ecially e?ui))ed high bio,safety level laboratories, i.e. Confirmation of )resence of 5g7 or 5g@ antibodies in serum by =A5:. 3etection of viral nucleic acid in s)ecimen by *C8 5solation of virus

Management of the case and biological materials

. sus)ected case of CCHF should be managed by diagnosing and treating for other likely causes of fever. 5f there is no res)onse to anti,malarial and antibiotic treatment, the )atientBs )latelet count should be checked and e>amined in view of the criteria mentioned above for C)robable CCHFD. .ll s)ecimens of blood or tissues taken for diagnostic )ur)oses should be collected and handled using universal safety )recautions. ( 5f the case meets the criteria for )robable CCHF, begin isolation )recautions, alert health facility staff, re)ort the case immediately, draw blood sam)les for CCHF diagnostic confirmation, and start treatment )rotocol below without waiting for confirmation. *atients with )robable or confirmed CCHF should be isolated and cared for using barrier,nursing techni?ues E masks, goggles, gloves, gowns and )ro)er removal and dis)osal of contaminated articles. *lease see Bo>,2. :)ecimens of blood or tissues of )robable CCHF cases should be tested only in high,level bio,safety laboratory.

reatment Protocol
7eneral su))ortive thera)y is the mainstay of )atient management in CCHF. 5ntensive monitoring to guide volume and blood com)onent re)lacement is recommended. 2,+,; 5f the )atient meets the case definition for )robable CCHF, ribavirin treatment )rotocol (Bo>, %) needs to be initiated immediately with the consent of the )atient9 relatives and the attending )hysician. 2,&,%#,

Note< 8ibavirin is not s)ecific treatment for CCHF viral infection but it has been documented that it can hel) in the treatment of CCHF infection and it should be started in consultation with )hysician. *lease note that )regnancy should be absolutely )revented (whether female or male )artner) within si> months of com)leting a course of ribavirin.

Proph!la"is Protocol
5n case of known direct contact with the blood or secretions of a )robable or confirmed case such as needle stick in4ury or contact with mucous membranes such as eye or mouth, the recommended )rocedure is to do baseline blood studies and start the )erson on the ribavirin )rotocol in Bo> % with consultation of )hysician. '

6o,&%. !reatment Protocol for CCH+ disease High,dose oral 7ibavirin thera)y constitutes the following< gm loading dose ' gm9day in ' divided doses (( hourly) for ' days. gm9day in ' divided doses for ( days.

Household or other contacts of the case who may have had the same e>)osure to infected ticks or animals, or who recall indirect contact with case body fluids should be monitored for %' days from the date of last contact with the )atient or other source of infection by taking the tem)erature twice daily. 5f the )atient develo)s a tem)erature of 2;." C or greater, headache and muscle )ains, he9she would be considered a )robable case and should be admitted to hos)ital and started on ribavirin treatment as mentioned in Bo>,%. '

Prevention and Control: Public#,$,%

%) =ducate )ublic about the mode of transmission through tick bites, handling ticks, and handling and butchering animals, and the means for )ersonal )rotection. ) $ick control with acaricide (chemicals intended to kill ticks) is a realistic o)tion for well, managed livestock )roduction facilities. .nimal di))ing in an insecticide solution is recommended. 2) *ublic should avoid tick,infested areas when feasible es)ecially when ticks are active (s)ring to fall). $o minimi/e e>)osure, wear light clothing that covers legs and arms, tuck )ants into socks, regularly e>amine clothing and skin for ticks, and a))ly tick re)ellent such as diethyltoluamide (3eetF, .utanF) to the skin or )ermethrin (a re)ellent and contact acaricide) to )ant legs and sleeves. ') *ersons who work with livestock or other animals in the endemic areas should take )ractical measures to )rotect themselves. $hey include the use of re)ellents on the skin (e.g. 3==$) and clothing (e.g. 689&( :afe 6urial practices4 )ermethrin) and $hick and long rubber gloves or double )air of surgical wearing gloves or gloves should be used for washing the body for burial. other )rotective $he dead body should be s)rayed with %<%# li?uid bleach clothing to )revent solution and then wra))ed in the winding sheet. skin contact with $he winding sheet should be s)rayed with bleach solution. infected tissues or 5t should then be )laced in a )lastic bag which should be blood. sealed with adhesive ta)e. ") 5n case of death of 3isinfect the trans)ort vehicle and burn all clothing of the CCHF )atient, deceased. family should be informed to follow safe burial )ractices (Bo>, ). 2

Prevention and Control: Hospitals and Health Facilities

%) ) Hos)itals should maintain stock of 8ibavirinG in *akistan it is available in the market as 8iba/oleF. Bio,safety is the key to avoiding nosocomial infection. *atients with sus)ected or confirmed CCHF should be isolated and cared for using barrier,nursing techni?ues to )revent nosocomial s)read of infection. (Bo>,2).

6o,&). 6io&safet2 measures4

%) ) 2) ') $he )atient should be treated in a se)arate room under strict barrier nursing. 6nly designated medical 9 )ara,medical staff and attendants should attend the )atient. Non,essential staff and attendants should not be allowed to enter the room. .ll secretions of the )atient and hos)ital clothing in use of the )atient should be treated as infectious and should be autoclaved before incinerating. .ll medical and )ara,medical staff and attendants should wear dis)osable gloves, dis)osable masks and gowns (gowns should be autoclaved before sending to the laundry or incineration). Hse of dis)osable items should be ensured by su)ervisor. ") =very effort should be made to avoid s)ills, )ricks, in4ury and accidents during the management of )atients. Needles should not be re,ca))ed but discarded in )ro)er safety dis)osal bo>. () +) ;) &) .ll used material e.g. syringes, gloves, canulla, tubing etc, should be collected in autoclave,able bag and autoclaved before incinerating. .ll instruments should be de,contaminated and autoclaved before re,use. .ll surfaces should be decontaminated with li?uid bleach. $he sam)les for laboratory testing should be )ro)erly collected, labelled, sealed, and decontaminated from outside with li?uid bleach and )acked in tri)le container )acking. %#) $he designated laboratory should be informed about the sam)le and it should be trans)orted to the designated laboratory with great caution, ensuring there would be no breakage or s)ills. %%) % ) .fter the )atient is discharged, room surfaces should be wi)ed down with li?uid bleach to kill the virus and the room should be fumigated. *lease see other instructions for contacts of a CCHF case, below.

'

Instructions for 0onitoring and Laborator2 !esting for Contacts of CCH+ Cases1
%. Definition of ;contact< a. *eo)le who were e>)osed to the same animal(s) as the )atient. b. @embers of the )atientIs family or others who were e>)osed to the sick )atient. c. Health workers who were e>)osed to the sick )atient, i.e. while )hysically e>amining or treating the )atient. d. Health workers who e>)erienced accidental needle stick in4ury or other accident where blood or secretions of )atient were in direct contact with o)en wound or mucous membrane. a. .ll contacts, e>ce)t Jd. above, should sim)ly be monitored for %' days (ma>imum) from the day of last contact with the )atient or other source of infection b! taking temperature t&ice dail!' $hey should have baseline blood tests and start ribavirin onl! if they become genuinely sick, i.e. i. $em)erature e?ual to or more than 2;."KC ii. :evere headache iii. @yalgia (muscle )ains) b. Contacts who have had clear cut e>)osure, see Jd. above, should have baseline blood tests directly after the accident and then be )laced on )ro)hylactic oral ribavirin. c. C.H$56N< . knowledgeable )hysician should be consulted about starting ribavirin and monitoring the )atient during treatment, and the )atient should be advised about the )otential side effects of treatment and the necessity of absolutely )reventing )regnancy (whether female or male )artner) within si> months of com)leting a course of ribavirin. a. $here is no )oint in testing the blood for CCHF confirmation during the first %' days after contact unless they are genuinely sick. b. 6btain blood tests to confirm CCHF onl! &hen contact gets definitely sick during the monitoring )eriod (%' days), i. 5ncreased body tem)erature e?ual to or L2;."C, ii. Headache and myalgia. c. .fter the %',day observation )eriod, one may consider testing the blood of a contact for research )ur)oses, to confirm whether they did or did not undergo sub,clinical infection

(. 0onitoring contacts

). !esting blood for CCH+

"

References:
%. Chin 0. ###. Control of Communicable 3iseases @anual. .merican *ublic Health .ssociation, seventh edition, )g "'G -ashington 3C. . 1akar, F. ##'. *resentation at -orld Health 6rgani/ation 5nter,Country @eeting on =merging 5nfectious 3iseases, Beirut, (,; .)ril ##'. 2. :heikh .:, :heikh .., :heikh N:, $ari? @. ##'. 8ibavirin< an effective treatment of Crimean,Congo Haemorrhagic Fever. *ak 0 @ed :ci #(2)< #%, #(. '. :wane)oel 8. ##'. :)ecial *athogens Hnit, National 5nstitute for Communicable 3iseases, :outh .frica, direct communication with Mirology :ection, *ublic Health Aaboratories 3ivision, National 5nstitute of Health, 5slamabad, %% 6ctober ##'. ". National 5nstitute of Health. ## . Case 3efinitions, @anagement and *revention of 5nfectious 3iseases. 3isease =arly -arning :ystem (3=-:), .ugust ## . (. Centers for 3isease Control and *revention and -orld Health 6rgani/ation. %&&;. 5nfection Control for Miral Haemorrhagic Fevers in the .frican Health Care :etting, :e)tember %&&;. -H69=@C9=:$9&;. +. Aee 78, et al. (eds.) %&&;. -introbeIs Clinical Hematology. *art M 3isorders of Hemostasis and Coagulation. .c?uired Coagulation 3isorders. )). %+2&,%+'&. NN< Ai))incott, -illiams O -ilkins. ;. *antanowit/ A. ##2. @echanisms of thrombocyto)enia in tick,borne diseases. $he 5nternet 0ournal of 5nfectious 3iseases. Molume , Number . htt)<99www.is)ub.com9ostia9inde>.)h), accessed %; 6ctober ##'. &. .thar @N, Ba?ai HP, .hmad @, 1halid @., Bashir N, .hmad .@, Balouch .H, Bashir 1. ##2. :hort 8e)ort< Crimean,Congo Hemorrhagic Fever outbreak in 8awal)indi, *akistan, February ## . .m 0 $ro) @ed Hyg (&(2)< ;', ;+. %#. Fisher,Hoch :*, 1han 0., 8ehman :, @ir/a:, 1hurshid @, @cCormick 0B, %&&". Crimean,Congo Haemorrhagic Fever treated with oral 8ibavirin. Aancet 2'(<'+ ,". %%. :chering Cor)oration. *roduct 5nformation 8ebetol (ribavirin, H:*) Ca)sules and 6ral :olution. ##'. htt)<99www.s)files.com9)irebetol.)df, accessed %; 6ctober ##'. % . -orld Health 6rgani/ation. %&&&. -H6 8ecommended :urveillance :tandards. -H69C3:9C:895:89&&.

These Guidelines have been produced in collaboration with the Global Infectious Disease Surveillance and Alert System (GIDSAS) project of Johns op!ins "niversity School of #edicine and $loomber% School of &ublic ealth' $altimore' "SA' and the (orld ealth )r%ani*ation' &a!istan+ ,ovember -../+