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OpenWHO.org 1
©WHO2017
Introduction to
Crimean-Congo
Haemorrhagic Fever
Managing
infectious hazards
Protect yourself
from tick bites
2
©WHO2018
Learning objectives
• Describe signs, symptoms, and
transmission of Crimean-Congo
Haemorrhagic Fever (CCHF)
• List 4 preventive and control measures
• Describe areas where CCHF is a public
health concern. Wikimedia commons/ Friend of Darwinek
3
©WHO2018
Crimean-Congo Haemorrhagic Fever Disease
• 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.
NICD South Africa/R. Swanepoel
4
©WHO2018
Geographic distribution of CCHF
Map available at: http:/www.who.int/csr/disease/crimean_congoHF/Global_CCHFRisk_2017.jpg?ua=1
5
©WHO2018
Burden of Crimean-Congo Haemorrhagic Fever
Endemic in
Africa, Balkans,
Middle East
and Asia
• 3 billion people at risk
• Estimated 500 deaths
each year
• Estimated 10,000 to 15,000
Crimean-Congo Haemorrhagic Fever infections each year
6
©WHO2018 6
Crimean-Congo Haemorrhagic Fever Transmission
• In nature, CCHF virus maintains
itself in a cycle involving ticks and
vertebrate.
• Most animals don't show
symptoms.
Reservoir Hyalomma ticks
80 to 90 % of humans are infected
through:
• tick bite or direct contact with
blood of infected ticks;
• direct contact with blood/tissues
of infected wild animals and
livestock.
• Secondary human-to-human
transmission occurs through direct
contact with the blood, secretions,
organs or other body fluids of
infected persons.
• High transmission risk when
providing direct patient care or
handling dead bodies (funerals).
Primary human infections Secondary human infections
Small mammals and birds
7
©WHO2018
Clinical features of CCHF disease
• 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.
• Case fatality ratio can reach 15% among patients
hospitalized with severe presentation.
• 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. NICD South Africa/R. Swanepoel
8
©WHO2018
Incubation
2-14 days
Pre-hemorrhagic period
1-7 days
Hemorrhagic period
2-3 days
Convalescence
Bleeding from various sites
(hematemesis, melena, etc.)
somnolence
Myalgia, Fever,
Nausea-vomiting,
Diarrhea
Day 7 Day 10 Days
Polymerase Chain Reaction: the first 10 days after onset of symptoms
IgM (7 days-4 months) and IgG (7 days-5 years)
Death (around 15%)
Fever
Virus / Antigen
IgG ELISA antibodies
IgM ELISA antibodies
Evolution of CCHF symptoms
Onset of
symptoms
9
©WHO2018
Crimean-Congo Haemorrhagic Fever diagnosis
• Symptoms are non-specific; clinical diagnosis may be
difficult.
• Differential diagnosis includes other viral haemorrhagic
fevers, malaria, typhoid fever, shigellosis, and other
viral and bacterial diseases.
• Patient history is essential and should include:
 exposure to ticks;
 or exposure to wild animals and livestock;
 and/or area/village endemic for CCHF;
 and/or contact with CCHF cases.
10
©WHO2018
Laboratory diagnosis of CCHF
Definitive diagnosis requires testing:
• reverse transcriptase polymerase chain reaction
(RT-PCR) assay;
• IgG and IgM antibodies enzyme-linked
immunosorbent assay (ELISA);
• antigen detection tests;
• virus isolation by cell culture.
Handling and processing specimen requires suitably equipped laboratories under
maximum biological containment conditions and staff collecting samples should be
trained
11
©WHO2018
Crimean-Congo Haemorrhagic Fever Treatment
• Early aggressive intensive care support: monitor
fluid, electrolyte balance, renal function, blood
pressure, and oxygenation, and careful
rehydration
• Support of coagulation system with blood
component therapy.
• Supportive drug therapy including : painkillers,
antiemetic for vomiting, anxiolytic for agitation,
+/-antibiotics and/or antimalarial drugs.
• Antiviral drug ribavirin can be given early in
course of the disease.
12
©WHO2018
Key components for CCHF control
Cases investigation Care for sick people
Preventive measures in communities
and health care settings
National
leadership
13
©WHO2018
General strategy to control CCHF outbreaks
Behavioural and
social
interventions
Clinical case
management
Logistics
Epidemiological
investigation,
surveillance
and laboratory
• Security, police
• Lodging, food
• Social and epidemiological
mobile teams
• Finances, salaries
• Transport vehicles
• Engage with key influencers:
women and /or youth associations,
traditional healers, local
authorities, religious & opinion
leaders
• Formal and informal
communication
• Address community concerns
Coordination
• Triage in/out
• Barrier nursing
• Infection control
• Organize funerals
• Clinical trials
• Ethics committee
Medias
Ethical
aspects
• Active case-finding
• Follow-up of contacts
• Specimens
• Laboratory testing
• Database analysis
• Search for the source
Psycho-social
support
Control of
vectors and
reservoirs in
nature
• Conduct social and cultural assessments
14
©WHO2018
Community engagement and awareness
• Engage with communities to promote
desired health practices and behaviours,
including reduction of ticks exposure and
safe meat preparation.
• Provide accurate and timely health advice
and information on the disease.
About Ticks
Ticks live in the ground vegetation and
move mainly by climbing up plants and
walking on the ground. They latch on to
a passing animal or human host by using
hooks on their legs.
Illustration is only indicative. Sizes can vary from 0.5
to 15 mm, depending on tick species.
Image courtesy of the European Centre for Disease Prevention and
Control (ECDC)
15
©WHO2018
Reducing risk of Ticks-to-human transmission
• Protect yourself from tick bites
1. Avoid tick-infested areas.
2. Wear light colored clothing for easy finding of ticks on
clothes.
3. Wear protective clothing (long sleeves, long pants).
4. Tuck your pant legs into your socks so that ticks cannot crawl
up inside of your pant legs.
5. Use chemical repellent with DEET (on skin) and acaricides
(tick killer) on boots and clothing.
• Perform daily tick checks : regularly examine clothes and
skin in search of ticks and remove them.
1
2
3
4
5
Image courtesy of zecken.de
16
©WHO2018
• Use fine-tipped tweezers (or a thread) .
• Grab the tick as close as possible to the skin.
• DO NOT twist or jerk the tick.
• Gently pull straight up until all parts of the
ticks are removed.
• Wash hands with soap and water. Apply
antiseptic on tick bite or clean with soap and
water.
• NEVER crush a tick with your fingers.
CCHF prevention: Safely remove ticks
Images courtesy of the US Centers for Disease
Control and Prevention (CDC)
17
©WHO2018
Reducing human-to-human transmission
• Avoid contact with infected CCHF
patients and deceased.
• Wash hands regularly with soap and
water.
• Encourage early treatment in CCHF
Treatment Center.
• Use gloves and mask and practice
hand-hygiene when caring for
suspected CCHF patient at home. Seek
health advice.
Crimean-Congo Haemorrhagic Fever?
18
©WHO2018
Controlling infection in health-care settings
• Implement Standard Precautions with all patients – regardless of their
diagnosis – in all work practices at all times including safe injection
practices. http://www.who.int/csr/resources/publications/standardprecautions/en/index.html
• Health care workers treating patient with CCHF should apply extra
infection control measures to prevent contact with the patient’s blood
and body fluids and contaminated surfaces or materials such as clothing
and bedding.
http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/?ua=1
• Laboratory workers are also at risk. Samples taken from suspected
human CCHF cases for diagnosis should be handled by trained staff and
processed in suitably equipped laboratories.
19
©WHO2018
• Reduce ticks in the environment: use acaricide (tick killer) in farms
and livestock production facilities to decrease tick infestations on
animals or in stables/barns. Tick control with acaricides is only a
realistic option for well-managed livestock production facilities.
• Quarantine for animals before they enter slaughterhouses or
routinely treat ruminants with acaricides 4 weeks prior to slaughter.
This activity will decrease the risk of the animal being viraemic
during slaughter.
• Wear mask, gloves and gowns when slaughtering and butchering
animals in slaughterhouses or at home to prevent skin contact with
infected animal tissue or blood.
CCHF : prevention in animal settings
20
©WHO2018
• Difficult to control environmental factors.
• Difficult to diagnose patients based on
clinical presentation.
Key Challenges for CCHF
• Case investigation to confirm mode of
transmission/exposure.
21
©WHO2018
• Close to patient diagnostic tests are in
late stage of assessment.
• Candidate drugs are in early stages of
testing.
• Vaccines are in development.
• Affected countries are at the heart of
R&D product development.
Research and development for CCHF
22
©WHO2018
WHO information on CCHF
• Technical information
• Fact Sheet
• Disease outbreak news
• CCHF map
• Related links
中文 English Français Русский Español ‫عربي‬
www.who.int/emergencies/diseases/crimean-congo-haemorrhagic-fever/en/
23
©WHO2018
Key contact
•Dr Pierre Formenty
-----------------------------------------
Infectious Hazard Management
Health Emergency Programme
WHO Geneva
formentyp@who.int

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introduction-to-crimean-congo-haemorrhagic-fever.pdf

  • 1. OpenWHO.org 1 ©WHO2017 Introduction to Crimean-Congo Haemorrhagic Fever Managing infectious hazards Protect yourself from tick bites
  • 2. 2 ©WHO2018 Learning objectives • Describe signs, symptoms, and transmission of Crimean-Congo Haemorrhagic Fever (CCHF) • List 4 preventive and control measures • Describe areas where CCHF is a public health concern. Wikimedia commons/ Friend of Darwinek
  • 3. 3 ©WHO2018 Crimean-Congo Haemorrhagic Fever Disease • 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. NICD South Africa/R. Swanepoel
  • 4. 4 ©WHO2018 Geographic distribution of CCHF Map available at: http:/www.who.int/csr/disease/crimean_congoHF/Global_CCHFRisk_2017.jpg?ua=1
  • 5. 5 ©WHO2018 Burden of Crimean-Congo Haemorrhagic Fever Endemic in Africa, Balkans, Middle East and Asia • 3 billion people at risk • Estimated 500 deaths each year • Estimated 10,000 to 15,000 Crimean-Congo Haemorrhagic Fever infections each year
  • 6. 6 ©WHO2018 6 Crimean-Congo Haemorrhagic Fever Transmission • In nature, CCHF virus maintains itself in a cycle involving ticks and vertebrate. • Most animals don't show symptoms. Reservoir Hyalomma ticks 80 to 90 % of humans are infected through: • tick bite or direct contact with blood of infected ticks; • direct contact with blood/tissues of infected wild animals and livestock. • Secondary human-to-human transmission occurs through direct contact with the blood, secretions, organs or other body fluids of infected persons. • High transmission risk when providing direct patient care or handling dead bodies (funerals). Primary human infections Secondary human infections Small mammals and birds
  • 7. 7 ©WHO2018 Clinical features of CCHF disease • 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. • Case fatality ratio can reach 15% among patients hospitalized with severe presentation. • 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. NICD South Africa/R. Swanepoel
  • 8. 8 ©WHO2018 Incubation 2-14 days Pre-hemorrhagic period 1-7 days Hemorrhagic period 2-3 days Convalescence Bleeding from various sites (hematemesis, melena, etc.) somnolence Myalgia, Fever, Nausea-vomiting, Diarrhea Day 7 Day 10 Days Polymerase Chain Reaction: the first 10 days after onset of symptoms IgM (7 days-4 months) and IgG (7 days-5 years) Death (around 15%) Fever Virus / Antigen IgG ELISA antibodies IgM ELISA antibodies Evolution of CCHF symptoms Onset of symptoms
  • 9. 9 ©WHO2018 Crimean-Congo Haemorrhagic Fever diagnosis • Symptoms are non-specific; clinical diagnosis may be difficult. • Differential diagnosis includes other viral haemorrhagic fevers, malaria, typhoid fever, shigellosis, and other viral and bacterial diseases. • Patient history is essential and should include:  exposure to ticks;  or exposure to wild animals and livestock;  and/or area/village endemic for CCHF;  and/or contact with CCHF cases.
  • 10. 10 ©WHO2018 Laboratory diagnosis of CCHF Definitive diagnosis requires testing: • reverse transcriptase polymerase chain reaction (RT-PCR) assay; • IgG and IgM antibodies enzyme-linked immunosorbent assay (ELISA); • antigen detection tests; • virus isolation by cell culture. Handling and processing specimen requires suitably equipped laboratories under maximum biological containment conditions and staff collecting samples should be trained
  • 11. 11 ©WHO2018 Crimean-Congo Haemorrhagic Fever Treatment • Early aggressive intensive care support: monitor fluid, electrolyte balance, renal function, blood pressure, and oxygenation, and careful rehydration • Support of coagulation system with blood component therapy. • Supportive drug therapy including : painkillers, antiemetic for vomiting, anxiolytic for agitation, +/-antibiotics and/or antimalarial drugs. • Antiviral drug ribavirin can be given early in course of the disease.
  • 12. 12 ©WHO2018 Key components for CCHF control Cases investigation Care for sick people Preventive measures in communities and health care settings National leadership
  • 13. 13 ©WHO2018 General strategy to control CCHF outbreaks Behavioural and social interventions Clinical case management Logistics Epidemiological investigation, surveillance and laboratory • Security, police • Lodging, food • Social and epidemiological mobile teams • Finances, salaries • Transport vehicles • Engage with key influencers: women and /or youth associations, traditional healers, local authorities, religious & opinion leaders • Formal and informal communication • Address community concerns Coordination • Triage in/out • Barrier nursing • Infection control • Organize funerals • Clinical trials • Ethics committee Medias Ethical aspects • Active case-finding • Follow-up of contacts • Specimens • Laboratory testing • Database analysis • Search for the source Psycho-social support Control of vectors and reservoirs in nature • Conduct social and cultural assessments
  • 14. 14 ©WHO2018 Community engagement and awareness • Engage with communities to promote desired health practices and behaviours, including reduction of ticks exposure and safe meat preparation. • Provide accurate and timely health advice and information on the disease. About Ticks Ticks live in the ground vegetation and move mainly by climbing up plants and walking on the ground. They latch on to a passing animal or human host by using hooks on their legs. Illustration is only indicative. Sizes can vary from 0.5 to 15 mm, depending on tick species. Image courtesy of the European Centre for Disease Prevention and Control (ECDC)
  • 15. 15 ©WHO2018 Reducing risk of Ticks-to-human transmission • Protect yourself from tick bites 1. Avoid tick-infested areas. 2. Wear light colored clothing for easy finding of ticks on clothes. 3. Wear protective clothing (long sleeves, long pants). 4. Tuck your pant legs into your socks so that ticks cannot crawl up inside of your pant legs. 5. Use chemical repellent with DEET (on skin) and acaricides (tick killer) on boots and clothing. • Perform daily tick checks : regularly examine clothes and skin in search of ticks and remove them. 1 2 3 4 5 Image courtesy of zecken.de
  • 16. 16 ©WHO2018 • Use fine-tipped tweezers (or a thread) . • Grab the tick as close as possible to the skin. • DO NOT twist or jerk the tick. • Gently pull straight up until all parts of the ticks are removed. • Wash hands with soap and water. Apply antiseptic on tick bite or clean with soap and water. • NEVER crush a tick with your fingers. CCHF prevention: Safely remove ticks Images courtesy of the US Centers for Disease Control and Prevention (CDC)
  • 17. 17 ©WHO2018 Reducing human-to-human transmission • Avoid contact with infected CCHF patients and deceased. • Wash hands regularly with soap and water. • Encourage early treatment in CCHF Treatment Center. • Use gloves and mask and practice hand-hygiene when caring for suspected CCHF patient at home. Seek health advice. Crimean-Congo Haemorrhagic Fever?
  • 18. 18 ©WHO2018 Controlling infection in health-care settings • Implement Standard Precautions with all patients – regardless of their diagnosis – in all work practices at all times including safe injection practices. http://www.who.int/csr/resources/publications/standardprecautions/en/index.html • Health care workers treating patient with CCHF should apply extra infection control measures to prevent contact with the patient’s blood and body fluids and contaminated surfaces or materials such as clothing and bedding. http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/?ua=1 • Laboratory workers are also at risk. Samples taken from suspected human CCHF cases for diagnosis should be handled by trained staff and processed in suitably equipped laboratories.
  • 19. 19 ©WHO2018 • Reduce ticks in the environment: use acaricide (tick killer) in farms and livestock production facilities to decrease tick infestations on animals or in stables/barns. Tick control with acaricides is only a realistic option for well-managed livestock production facilities. • Quarantine for animals before they enter slaughterhouses or routinely treat ruminants with acaricides 4 weeks prior to slaughter. This activity will decrease the risk of the animal being viraemic during slaughter. • Wear mask, gloves and gowns when slaughtering and butchering animals in slaughterhouses or at home to prevent skin contact with infected animal tissue or blood. CCHF : prevention in animal settings
  • 20. 20 ©WHO2018 • Difficult to control environmental factors. • Difficult to diagnose patients based on clinical presentation. Key Challenges for CCHF • Case investigation to confirm mode of transmission/exposure.
  • 21. 21 ©WHO2018 • Close to patient diagnostic tests are in late stage of assessment. • Candidate drugs are in early stages of testing. • Vaccines are in development. • Affected countries are at the heart of R&D product development. Research and development for CCHF
  • 22. 22 ©WHO2018 WHO information on CCHF • Technical information • Fact Sheet • Disease outbreak news • CCHF map • Related links 中文 English Français Русский Español ‫عربي‬ www.who.int/emergencies/diseases/crimean-congo-haemorrhagic-fever/en/
  • 23. 23 ©WHO2018 Key contact •Dr Pierre Formenty ----------------------------------------- Infectious Hazard Management Health Emergency Programme WHO Geneva formentyp@who.int