Friday, 23 January 2015

IMA White Paper on Crimean-Congo Hemorrhagic Fever: No panic

IMA White Paper on Crimean-Congo Hemorrhagic Fever: No panic

National Institute of Virology in Pune  has confirmed a 35-year-old male nurse who died of extensive internal bleeding at AIIMS was suffering from Congo contagious fever. The male nurse from a private Jodhpur hospital, was among five members of the nursing staff who developed flu like symptoms. Two nurses showed a fall in blood platelet count and suffered internal bleeding with one dying on Sunday in Jodhpur while the other died of multi-organ failure after being admitted to AIIMS with Ebola-like symptoms.

Indian Medical Association, National President  today released a white paper on  Crimean-Congo Hemorrhagic Fever for the benefit of its members and public. The paper in the form of question and answers is compiled by Padma Shri Awardee Prof Dr K K Aggarwal Honorary Secretary General IMA.

No panic said IMA. Its not a new disease in India. 

What are hemorrhagic fevers?

                1. Dengue
                2. Yellow fever
                3. Ebola
                4. Marburg hemorrhagic fever. It is rare and limited to countries in Central Africa
                5. Crimean-Congo hemorrhagic fever

What is Crimean-Congo hemorrhagic fever?

 A: It is a severe, potentially fatal disease in humans caused by CCHF  tick-borne virus (Nairovirus) of the Bunyaviridae family.

In which countries the disease is seen?

Africa, Asia, eastern Europe, and the Middle East.

Is it seen in India?
                    CCHF was first confirmed in a nosocomial outbreak in 2011 in Gujarat State. Another notifiable outbreak occurred in July, 2013, in Karyana Village, Amreli district, Gujarat State.
                    Anti-CCHF virus (CCHFV) immunoglobulin G (IgG) antibodies were detected in domestic animals from the adjoining villages of the affected area, indicating a considerable amount of positivity against domestic animals.
                    A study published in Vector Borne Zoonotic Dis. 2104 looked at the prevalence of CCHFV among bovine, sheep, and goat populations from 15 districts of Gujarat State and found antibodies in all the 15 districts surveyed; with positivity of 12.09%, 41.21%, and 33.62% in bovine, sheep, and goat respectively.

What is the mode of human transmission?

                    Transmission to humans occurs through tick bites, contact with a patient with CCHF during the acute stage of infection, or contact with blood or tissue from infected livestock.
                    Human-to-human transmission can occur resulting from close contact with the blood, secretions, organs or other bodily fluids of infected persons.

 What are the four distinct phases of the disease?

The typical course of CCHF has four distinct phases
·         Incubation
·         Pre-hemorrhagic
·         Hemorrhagic
·         Convalescence

What is the incubation period?

The incubation period that follows a tick bite is usually short (three to seven days).

What are the clinical symptoms?

·         The pre-hemorrhagic period is characterized by the sudden onset of fever, headache, myalgia, and dizziness.

·         Additional symptoms of diarrhea, nausea, and vomiting are also seen in some cases.

·         Nearly three days later , hemorrhagic manifestations from petechiae, large hematomas, and frank bleeding (vaginal, gastrointestinal, nose, urinary, and respiratory tracts) usually follow.

·         The convalescence period begins in survivors about 10 to 20 days after onset of illness.

How serious is the disease?

The case fatality rates range from 3 to 30 percent

What is the cause of death?

                    Disseminated intravascular coagulation
                    Vascular dysregulation
                    Higher serum levels of proinflammatory cytokines interleukin (IL)-6 and tumor necrosis factor (TNF)

What are the ultrasound findings?

Liver and spleen enlargement, paraceliac abdominal enlargement of lymph         nodes, gall bladder wall thickening, and intra-peritoneal and pleural effusion. These become prominent on the third day of disease in some patients.

How is the diagnosis made?

                    Viral isolation in bio-safety level four laboratories
                    2. IgM and IgG antibodies are detectable by ELISA and immunofluorescence               assays from about seven days after the onset of disease
                    Specific IgM antibodies decline to undetectable levels approximately four months after presentation.

What is the differential diagnosis?

All hemorrhagic fevers including dengue and ebola. All cases of dengue like illness with negative ebola or dengue test one should suspect it.

What is the treatment?

                    Treatment is mainly supportive.
                    Ribavirin is effective, to be given for 10 days (30 mg/kg as an initial loading dose, then 15 mg/kg every six hours for four days, and then 7.5 mg/kg every eight hours for six days)

Is a vaccine available?

There is no vaccine available for either people or animals.

What is the prevention?

                    Reducing the risk of human-to-human transmission in the community
                    Avoid close physical contact with CCHF-infected people;
                    Wear gloves and protective equipment when taking care of ill people;
                    Wash hands regularly after caring for or visiting ill people.
                    Health-care workers caring for patients with suspected or confirmed CCHF, or handling specimens from them, should implement standard infection control precautions. These include basic hand hygiene, use of personal protective equipment, safe injection practices and safe burial practices.

What is common in homorganic fevers?

Vascular dys-regulation with severe intravascular leak. Clinical it will present with low pulse pressure. And responds to massive vascular resuscitation with fluids.

What is the clinical clue?

Dengue like illness, pleural effusion on ultrasound, gall bladder thickening in ultrasound, negative dengue serology and signs of intra vascular leak.

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