Few facts about CCHF

1. Dr Lázaro Nicanor Rodríguez Gonzalez.MD.
Department of Internal Medicine .
RMS Hospital(Kimberley Hospital).
1/4/2019

2.  •CCHF is viral illness that occurs in Africa, the Balkans, the Middle East and
Asia, in countries south of the 50° parallel north.
 •The principal reservoir and vector of CCHF are ticks of the genus Hyalomma,
although other tick genera can be infected with CCHF virus.
 •The CCHF virus is transmitted to humans mainly by tick bites or through
contact with infected animal blood or tissues during and immediately after
slaughter.
 •88% of people infected will have subclinical symptoms. One in eight people will
develop a severe disease.

3. The disease was first described in the Crimea in 1944 and
given the name Crimean haemorrhagic fever. In 1969 it
was recognized that the pathogen causing Crimean
haemorrhagic fever was the same as that responsible for
an illness identified in 1956 in the Congo, and linkage of
the two place names resulted in the current name for the
disease and the virus.

4.  Ticks of the genus Hyalomma are the principal vector of Crimean-Congo haemorrhagic
fever. Female (right), male (left).

5.  Crimean-Congo hemorrhagic fever virus (CCHFV) is a member of the Nairovirus
genus within the family Bunyaviridae, which contains negative-stranded,
enveloped RNA viruses

6. The risk of community-based transmission to close contacts and relatives of
patients with CCHF is low.

7.  The risk is highest during later stages of disease which are associated with higher
viral loads as well as diarrhea, vomiting, and hemorrhage .Direct contact withblood
and body fluids, needle-stick injuries, and splash exposures are common causes of
nosocomial transmission
 Transmission between patients sharing the same hospital room has occurred, likely
due to contact with infected blood or body fluids .
 Healthcare personnel are also at risk of infection during aerosol-generating
procedures.
 Vertical (mother-to-child) transmission of CCHFV has been described; in such cases,
fetal prognosis may be guarded .

8.  Breastfeeding has not been associated with CCHFV transmission.
 The role of sexual transmission is uncertain .CCHF with epididymo-orchitis has
been described as has detection of CCHFV in urine.
 The risk of laboratory exposure to CCHFV while processing blood samples is low if
routine laboratory procedures are followed.

9.  Individuals at risk for CCHFV infection include agricultural workers,
individuals in rural areas engaged in animal husbandry, abattoir workers,
veterinarians, leather factory workers in areas with high tick density.
Campers and hikers, hunters, soldiers, healthcare workers,
and travelers to endemic areas (particularly in the setting of exposure to farming
and slaughtering)

11. •The incubation period ranges from 2-14 days.
•70% of CCHF cases have a history of tick bite.
•It is estimated that 88% of infections are subclinical. (The spectrum of clinical
manifestations ranges from subclinical illness to acute infection with hemorrhage and
multiorgan failure).
•Case fatality ratio can reach 15% among patients hospitalized with severe
presentation with death occurring in the second week of illness. In patients who recover,
improvement generally begins on the ninth or tenth day after the onset of illness.
•Most common symptoms include:
•Abrupt onset fever, chills, shudders, myalgia, headaches, sicknesses and vomits,
abdominal pain, arthralgia;
•After a few days: bleeding from mucous membranes, hematomas, ecchymosis, melena,
hematuria, nose bleeding, vaginal bleeding, bradycardia, thrombocytopenia, leukopenia.

12.  Should be suspected in patients presenting with fever and bleeding who have relevant
geographic and epidemiologic risk factors (including exposure to an endemic region
within the previous two weeks in addition to known tick bite and/or contact with
animal tissue or body fluids).
 Diagnostic tools:
 Include detection of CCHF virus (CCHFV) RNA by reverse-transcriptase polymerase
chain reaction(RT-PCR) and specific immunoglobulin (Ig)M and IgG by enzyme-linked
immunosorbent assay (ELISA).
 CCHFV can be cultured in cell culture; this requires biosafety level 4 laboratories and
is only used for research purposes.

14.  Other viral hemorrhagic fevers.
 Meningococcemia
 Malaria.
 Rickettsial infection.
 Q fever.
 Leptospirosis.
 Idiopathic thrombocytopenic purpura.
 Acute leukemia

15. There is no proven antiviral
treatment for Crimean-
Congo hemorrhagic fever
(CCHF) infection

16.  .
 .
Ribavirin has not been shown
to reduce viral load or
mortality in humans and its
clinical efficacy is
controversial. In addition most
of the studies evaluating the
effectiveness of ribavirin are
limited by methodology flaws
,further study is needed

17.  Management of CCHF consists of supportive care; in severe cases, blood product
replacement is warranted .
 Patients with CCHF should be managed in a healthcare center with appropriate
facilities for diagnosis, treatment and prevention of disease, including isolation
precautions.
 Data are insufficient to support routine use of steroids, intravenous
immunoglobulin, or plasma exchange.
 Use of hyperimmunoglobulin (which is prepared from the plasma of donors with
antibody against CCHF) requires further study. Hyperimmunoglobulin can
decrease viral load via direct neutralization, although viral strain variability may
be an important determination in the use of this therapy.

18.  Supportive treatment is essential for management of CCHF .Careful
attention should be paid to fluid balance and electrolytes.
Mechanical ventilation, hemodialysis, vasopressor, and inotropic
agents may be needed.
 Acetaminophen may be used for fever and pain management;
ibuprofen and aspirin should be avoided as these agents can
adversely affect normal clotting.
 Platelet transfusion is warranted to maintain platelet count
>50,000/mm in the setting of bleeding and for patients with platelet
count <20,000/mm in the absence of bleeding.
 The need for blood transfusion should be assessed based on the
hemoglobin level as well as the general clinical status. Unnecessary
interventional procedures should be avoided to minimize risk of
bleeding.

19.  Presence of hemorrhage (particularly gastrointestinal bleeding and hematuria),
central nervous system involvement, DIC, significant liver dysfunction, diarrhea,
leukocytosis and splenomegaly .
 In addition, CCHF virus RNA level >10 copies/mL is an important indicator for
mortality (positive predictive value 80 percent, sensitivity 89 percent, specificity
93 percent).

20.  Infection control precautions (including standard, contact, and droplet
precautions) should be implemented to prevent nosocomial transmission of CCHF
.
 Patients with suspected or confirmed CCHF should be treated in isolation rooms.
 The number of healthcare personnel entering patient rooms should be minimized.
 Healthcare worker training about CCHF transmission, exposure prevention, hand
hygiene, and use of personal protective equipment is essential .
 Contact precautions include appropriate personal protective equipment (an
impervious gown, gloves, mask, and eye/face protection) .
 Respiratory protection (N95 mask or FFP3 respirator) is required during aerosol-
generating procedures.
 Shoe covers are warranted when there is significant environmental
contamination. It is essential to remove and dispose of personal protective
equipment safely when leaving patient rooms.

21.  Using "safe-sharps" systems help prevent needle-stick injuries.
 Principles of safe phlebotomy should be adhered to,and needles must not be
recapped.
 All sharps and needles should be disposed of in hard containers and at the point of
use.

22.  No signs and symptoms of disease for at least three days, with a platelet count
>50,000/mm and normal coagulation tests (international normalized ratio,
prothrombin time, and activated partial thromboplastin time).
 If possible, a negative blood polymerase chain reaction for viral hemorrhagic fever
should also be documented

23.  The exposed individual should undergo a two-week period of monitoring for
symptoms or signs of CCHF, including daily temperature measurement and
weekly assessment of complete blood count measurement; no quarantine is
required.
 Development of a febrile illness during the monitoring period should prompt
diagnostic testing.
 The role of ribavirin for prevention of clinical illness when given as postexposure
prophylaxis is uncertain.

24.  CCHF virus can be inactivated by disinfectants including 1% sodium
hypochlorite(household bleach), 70% alcohol, 2% glutaraldehyde, hydrogen
peroxide, and peracetic acid, and the virus is susceptible to high temperature at
56°C for 30 minutes or 60°C for 15 minutes.
 Housekeeping staff should use personal protective equipment when cleaning.

25.  1. PROCEDURE AT THE REFERRAL HOSPITAL
 Referral of patients and/or admission of patients with suspected VHF in the Isolation
Unit in KHC can ONLY be done in consultation with the Specialist Physician ON
CALL for the Department of Internal Medicine.
 The Specialist Physician can be contacted through the switchboard at KHC: 053 802
9111. Contact the Specialist Physician on call for Internal Medicine to assist in the
categorization of the disease.
 All low category patients to be managed at district level
 Moderate and high risk patients must be transported to Kimberley –The decision on
the transfer of the patient will be made by the Specialist Physician on call for the
Department of Internal Medicine

26. Risk Stratification of patients with
suspected Congo Fever
Low Risk: Medium Risk High Risk
Managed in the district Moderate and high risk patients must be transported to Kimberley
Fever of unknown origin, flulike
symptoms, NO bleeding tendency
Febrile disease with features of VHF, not
severely ill, not overtly bleeding currently
Severely ill and bleeding at present
No history of animal contact History of animal contact up to 3 weeks
prior to illness
History of animal contact up to 3 weeks
prior to illness
No history of travelling to rural
area
History of travelling to rural area History of travelling to rural area
No contact with VHF patient No contact with VHF patient Contact with VHF patient, but not
necessarily very ill

27.  As soon as any doctor in the Accident and Emergency
Department receives a telephonic referral of a patient with
possible VHF, the caller must be referred to the Specialist
Physician on call for Internal Medicine.
 If the patient is a patient at KHC already, the doctor in charge
must discuss the patient with the Specialist Physician on call
for Internal Medicine.

28.  The Specialist Physician on call will decide when and whether the VHF protocol
should be activated. It is the responsibility of the Specialist Physician on call to
inform all the relevant managers, which include:
 Unit Manager and doctor of the Emergency Centre.
 Person in charge of EMS (0837448857/0834598413/6985)
 NHLS
 NICD hotline: 082883992
 Infection control.
 HOU Internal Medicine.
 Hospital CEO/Medical Director.
 After admission to the Isolation Unit, a dedicated Medical Officer from Internal
Medicine will provide ongoing medical care to the patient in consultation with the
admitting Specialist Physician.

29.  Take blood specimens for liver function tests, full blood count, P T T ,INR, CK,
Urea and Electrolytes, as well as specimens for NICD. Blood tubes should
include:
 2 purple top tubes
 2 yellow top tubes
 1 green top tube
 1 blue top tube
 Every blood tube should be placed in a separate plastic bag and each plastic
bag should be covered with a layer of cotton wool. The wrapped plastic bags
should then be packed in the special biohazardous container.
 The biohazardous container should then be taken to NHLS and left with the
Lab Technologist.
 If the patient is bleeding, Group O negative blood must be ordered from Blood
bank WITHOUT sending a Compact. Inform Dr. P. Wessels (082 770 3354) of
SANBS of the possible/confirmed Congo fever patient that has been admitted.