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/uidelines for 0anagement, Prevention and Control of Crimean&Congo Hemorrhagic +ever (CCH+)
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,%).
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
Probable case :us)ected case with acute history of febrile illness %# days or less. %) needs to be initiated immediately with the consent of the )atient9 relatives and the attending )hysician. 5f there is no res)onse to anti. 5f the )atient meets the case definition for )robable CCHF. .safety level laboratories. 2. 7um bleeding. malarial treatment. and start treatment )rotocol below without waiting for confirmation. goggles. gowns and )ro)er removal and dis)osal of contaminated articles. *atients with )robable or confirmed CCHF should be isolated and cared for using barrier.. sus)ected case of CCHF should be managed by diagnosing and treating for other likely causes of fever. 5ntensive monitoring to guide volume and blood com)onent re)lacement is recommended.nursing techni?ues E masks. and animal handlers). Haematemesis. begin isolation )recautions. =cchymosis.+. • Confirmation of )resence of 5g7 or 5g@ antibodies in serum by =A5:. 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.safety laboratory.level bio.Case definition Suspected Case *atient with sudden onset of illness with high. gloves. 2.###9mm2 5ND any two of the following< • *etechial or )ur)uric rash. Blood in stools. the )atientBs )latelet count should be checked and e>amined in view of the criteria mentioned above for C)robable CCHFD. Haemo)tysis.&. es)ecially in CCHF endemic area and among those in contact with shee) or other livestock (she)herds. • 3etection of viral nucleic acid in s)ecimen by *C8 • 5solation of virus Management of the case and biological materials .e.2.malarial and antibiotic treatment. i. butchers. . draw blood sam)les for CCHF diagnostic confirmation.grade fever over 2." °C for more than + hrs and less than %# days. )erformed in s)ecially e?ui))ed high bio..%#. *lease see Bo>. ribavirin treatment )rotocol (Bo>. :)ecimens of blood or tissues of )robable CCHF cases should be tested only in high. re)ort the case immediately. reatment Protocol 7eneral su))ortive thera)y is the mainstay of )atient management in CCHF. 5ND • $hrombocyto)enia less than "#. alert health facility staff. ( 5f the case meets the criteria for )robable CCHF.ll s)ecimens of blood or tissues taken for diagnostic )ur)oses should be collected and handled using universal safety )recautions. Note that fever is usually associated with headache and muscle )ains and does not res)ond to antibiotic or anti. =)ista>is.
*lease note that )regnancy should be absolutely )revented (whether female or male )artner) within si> months of com)leting a course of ribavirin. family should be informed to follow safe burial )ractices (Bo>.% %) =ducate )ublic about the mode of transmission through tick bites. ' 6o. the recommended )rocedure is to do baseline blood studies and start the )erson on the ribavirin )rotocol in Bo> % with consultation of )hysician. infected tissues or • 5t should then be )laced in a )lastic bag which should be blood.. ) $ick control with acaricide (chemicals intended to kill ticks) is a realistic o)tion for well. 2) *ublic should avoid tick. $hey include the use of re)ellents on the skin (e.$. handling ticks. 5f the )atient develo)s a tem)erature of 2. $o minimi/e e>)osure. he9she would be considered a )robable case and should be admitted to hos)ital and started on ribavirin treatment as mentioned in Bo>. 3==$) and clothing (e. . ). skin contact with • $he winding sheet should be s)rayed with bleach solution. headache and muscle )ains. 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. ' Prevention and Control: Public#.nimal di))ing in an insecticide solution is recommended.utanF) to the skin or )ermethrin (a re)ellent and contact acaricide) to )ant legs and sleeves. wear light clothing that covers legs and arms.&%. 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. . regularly e>amine clothing and skin for ticks. deceased.g. and a))ly tick re)ellent such as diethyltoluamide (3eetF. and handling and butchering animals. ") 5n case of death of • 3isinfect the trans)ort vehicle and burn all clothing of the CCHF )atient. and the means for )ersonal )rotection. ') *ersons who work with livestock or other animals in the endemic areas should take )ractical measures to )rotect themselves. gm9day in ' divided doses for ( days. !reatment Protocol for CCH+ disease High.dose oral 7ibavirin thera)y constitutes the following< gm loading dose ' gm9day in ' divided doses (( hourly) for ' days. 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. tuck )ants into socks.infested areas when feasible es)ecially when ticks are active (s)ring to fall).%. sealed with adhesive ta)e. managed livestock )roduction facilities.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. 2 .g." ° C or greater. 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. Household or other contacts of the case who may have had the same e>)osure to infected ticks or animals.
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.nursing techni?ues to )revent nosocomial s)read of infection. Bio. and decontaminated from outside with li?uid bleach and )acked in tri)le container )acking. *lease see other instructions for contacts of a CCHF case.ll used material e.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.able bag and autoclaved before incinerating.) &) . canulla. should be collected in autoclave.&). gloves.contaminated and autoclaved before re. ") =very effort should be made to avoid s)ills.ll medical and )ara. () +) .2). labelled.ca))ed but discarded in )ro)er safety dis)osal bo>. . syringes. 6io&safet2 measures4 %) ) 2) ') $he )atient should be treated in a se)arate room under strict barrier nursing. .ll surfaces should be decontaminated with li?uid bleach. Needles should not be re. room surfaces should be wi)ed down with li?uid bleach to kill the virus and the room should be fumigated. sealed. *atients with sus)ected or confirmed CCHF should be isolated and cared for using barrier.medical staff and attendants should attend the )atient.essential staff and attendants should not be allowed to enter the room. $he sam)les for laboratory testing should be )ro)erly collected. Hse of dis)osable items should be ensured by su)ervisor. ensuring there would be no breakage or s)ills. %%) % ) . 6o. %#) $he designated laboratory should be informed about the sam)le and it should be trans)orted to the designated laboratory with great caution.safety is the key to avoiding nosocomial infection. (Bo>.use. 6nly designated medical 9 )ara. in4ury and accidents during the management of )atients. tubing etc. ' . Non.medical staff and attendants should wear dis)osable gloves.g.fter the )atient is discharged.ll instruments should be de. below. )ricks. dis)osable masks and gowns (gowns should be autoclaved before sending to the laundry or incineration). . .
e>ce)t Jd.fter the %'. to confirm whether they did or did not undergo sub. c. @embers of the )atientIs family or others who were e>)osed to the sick )atient. above. a. b. 6btain blood tests to confirm CCHF onl! &hen contact gets definitely sick during the monitoring )eriod (%' days). i. $here is no )oint in testing the blood for CCHF confirmation during the first %' days after contact unless they are genuinely sick. !esting blood for CCH+ " . ."°C. Headache and myalgia. Definition of . .day observation )eriod. 5ncreased body tem)erature e?ual to or L2.ll contacts.contact< a. one may consider testing the blood of a contact for research )ur)oses.. c.. Health workers who were e>)osed to the sick )atient.Instructions for 0onitoring and Laborator2 !esting for Contacts of CCH+ Cases1 %. while )hysically e>amining or treating the )atient. should have baseline blood tests directly after the accident and then be )laced on )ro)hylactic oral ribavirin.clinical infection (. :evere headache iii. @yalgia (muscle )ains) b. knowledgeable )hysician should be consulted about starting ribavirin and monitoring the )atient during treatment. 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. see Jd. c. 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. b. d. a.e. above. C. 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."KC ii. *eo)le who were e>)osed to the same animal(s) as the )atient. i. i.H$56N< . Contacts who have had clear cut e>)osure.e. 0onitoring contacts ). ii. $em)erature e?ual to or more than 2.
. 6ctober ##'. :e)tember %&&. *roduct 5nformation 8ebetol (ribavirin. F.) %&&. 1hurshid @./+ ( .. .Congo Hemorrhagic Fever outbreak in 8awal)indi. ###. Beirut. ". . -illiams O -ilkins. &. 8ehman :. ##'. -introbeIs Clinical Hematology. %% 6ctober ##'. Ba?ai HP. Bashir 1.Congo Haemorrhagic Fever treated with oral 8ibavirin. %&&.frica.Congo Haemorrhagic Fever.merican *ublic Health . 3isease =arly -arning :ystem (3=-:).H.+. accessed %. . %#. :heikh N:.Hoch :*. H:*) Ca)sules and 6ral :olution. 1akar. *akistan. :)ecial *athogens Hnit.borne diseases..@. htt)<99www. %&&". :heikh .)h). 6ctober ##'. Centers for 3isease Control and *revention and -orld Health 6rgani/ation. htt)<99www.Country @eeting on =merging 5nfectious 3iseases. ##'.. )). Aee 78.)ril ##'. . -orld Health 6rgani/ation. *ak 0 @ed :ci #(2)< #%. 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+ . @anagement and *revention of 5nfectious 3iseases. %%. 2. +.com9)irebetol. (. :hort 8e)ort< Crimean... National 5nstitute for Communicable 3iseases.s)files.c?uired Coagulation 3isorders.ovember -. Bashir N. $ari? @. @ir/a:.:.. National 5nstitute of Health. :outh . Number . ##'. ##'. seventh edition. Control of Communicable 3iseases @anual. -H69=@C9=:$9&. 5slamabad.". :heikh .com9ostia9inde>. National 5nstitute of Health. *resentation at -orld Health 6rgani/ation 5nter. et al. $he 5nternet 0ournal of 5nfectious 3iseases..frican Health Care :etting. *ublic Health Aaboratories 3ivision. Crimean.is)ub. 8ibavirin< an effective treatment of Crimean. *antanowit/ A. %&&&. @cCormick 0B. @echanisms of thrombocyto)enia in tick. accessed %. Aancet 2'(<'+ . )g "'G -ashington 3C. Case 3efinitions. -H6 8ecommended :urveillance :tandards. . Molume .ssociation. :wane)oel 8.'. . . #(. ## .. 1halid @. .%+'&.ugust ## . -H69C3:9C:895:89&&. NN< Ai))incott.. Chin 0. February ## .hmad . 1han 0. *art M 3isorders of Hemostasis and Coagulation.)df.. % .hmad @. ##2. :chering Cor)oration. '..thar @N. Fisher. . ##2.m 0 $ro) @ed Hyg (&(2)< . %+2&. . (. (eds.References: %. direct communication with Mirology :ection. Balouch . 5nfection Control for Miral Haemorrhagic Fevers in the .
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