Crimean-Congo hemorrhagic fever, a tickborne viral disease, has a case-fatality rate from 2% to 30%. There are about 500 cases/year in Eastern Europe, Middle East, Africa, Central and Southern Asia.
CASES/YEAR
0 (US); 500 (Global)
OTHER NAMES
Central Asian hemorrhagic fever;
INCUBATION
1-12 days, usually 3-7 days; [CCDM]
INITIAL SYMPTOMS
In pre-hemorrhagic phase, patients have flu-like illness with fever, myalgia, and headache; [CCDM, p. 43]
PRECAUTIONS
Standard; "Single-patient room preferred. Emphasize: 1) use of sharps safety devices and safe work practices, 2) hand hygiene; 3) barrier protection against blood and body fluids upon entry into room (single gloves and fluid-resistant or impermeable gown, face/eye protection with masks, goggles or face shields); and 4) appropriate waste handling. Use N95 or higher respirators when performing aerosol-generating procedures. Largest viral load in final stages of illness when hemorrhage may occur; additional PPE, including double gloves, leg and shoe coverings may be used, especially in resource-limited settings where options for cleaning and laundry are limited. Notify public health officials immediately if Ebola is suspected. Also see Table 3 for Ebola as a bioterrorism agent." [CDC 2007 Guideline for Isolation Precautions]
COMMENTS
FINDINGS:
The case-fatality rate of this tickborne viral disease varies from 2% to 30%. Patients may develop vomiting, abdominal pain, diarrhea, conjunctivitis, petechial rash, and bleeding (gums, nose, lungs, uterus, urinary tract, and gastrointestinal). Laboratory findings include liver enzyme elevations, leukopenia, and thrombocytopenia. [CCDM, p. 43-4] Patients may have flushing of the face and chest, conjunctival injection, and palatal petechiae. The illness may be biphasic with a primary flu-like illness, a few days of remission, and then the secondary hemorrhagic phase. Findings in the second phase may include severe liver injury, bradycardia, pulmonary edema, and epistaxis. Bleeding from IV sites, the nose, and other mucosa is often heavy enough to cause anemia and hypotension. Marked abnormalities of platelet count, transaminase levels, and clotting factors, as well as leukocytosis, predict a fatal outcome. [ID, p. 2144-5] Other findings that are sometimes present: hepatomegaly, stiff neck, and sore throat; [WHO website]
EPIDEMIOLOGY:
The disease occurs where Hyalomma ticks live (tick bites or slaughtering animals infested with ticks). [Harrison ID, p. 968] Hospital workers may become infected after exposure to blood and secretions. Other cases result from workers handling the tissues of infected animals. Reservoirs include ticks plus amplifying hosts (sheep, cattle, ostriches, goats, wild herbivores, hedgehogs, and hares). [CCDM, p. 43-6] This virus does not replicate to high concentrations in cell cultures, and, therefore, is not likely to be used as a biological weapon. [JAMA]
CASE DEFINITION:
The WHO case definition of acute hemorrhagic fever syndrome includes any 2 of the following: hemorrhagic or purpuric rash, epistaxis, hematemesis, hemoptysis, and blood in the stools. [WHO website]
DIAGNOSTIC
Culture; PCR; Paired sera; "In most patients, virus-specific IgM and IgG antibodies can be detected by indirect IF or EIA on days 7 to 9 of illness, with IgM falling to low or undetectable levels by 3 to 5 months." [ID, p. 2145]
SCOPE
Eastern Europe, Middle East, Africa, Central and Southern Asia; [CCDM]
SIGNS & SYMPTOMS
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>fatigue, weakness
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>fever
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>fever, biphasic or relapsing
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>myalgia
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>relative bradycardia
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E epistaxis
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E pharyngitis
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E stomatitis
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G abdominal pain
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G blood in stool
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G diarrhea
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G hematemesis
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G hepatomegaly
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G jaundice
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G liver function test, abnormal
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G nausea, vomiting
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H anemia
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H leukocytosis
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H leukopenia
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H splenomegaly
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H thrombocytopenia
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N headache
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N stiff neck
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O conjunctivitis, acute
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R hemoptysis
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S petechiae and ecchymoses
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S rash (exanthem)
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U hematuria
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*bleeding tendency
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*hepatitis
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*pulmonary edema
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*shock
ENTRY
Inhalation, Needle (Includes Drug Abuse), Scalpel or Transfusion, Skin or Mucous Membranes (Includes Conjunctiva)
SOURCE
Person-to-Person, Animal Tissue
RESERVOIR
Birds and Poultry, Cattle, Goats and Sheep, Rabbits, Rodents, Human
RISK FACTORS
- Care for patients (bloodborne pathogen)
- Care for patients (droplet/airborne)
- Handle animal carcasses or placentas
- Handle needles or surgical instruments
- Travel to endemic area
- Victim--air release of infectious agents
- Work in a medical or research lab
- Work or play in tick-infested area
TREATMENT
Intravenous ribavirin may be of value early in the course; Convalescent plasma with high titer of neutralizing antibodies has been used but its effectiveness is unknown; [CCDM, p. 46]
REFERENCES FOR CASES/YEAR
1.
2. (Global) Cases reported in England & Wales: One case in a traveler from Afghanistan was confirmed in 2012; [Public Health England website] From 1953 to 1974, 1,105 CCHFV cases were reported to the Bulgarian Ministry of Health; Between 1975 and 1996, the number of reported CCHF cases was reduced to 279; In 2002 and 2003, a total of 19 persons in Turkey had suspected cases of Crimean-Congo hemorrhagic fever (CCHF); 17 confirmed CCHF cases in 2010, all in residents of Southern Kazakhstan Oblast; [From 3 articles published on CDC website] About 500 cases/year; [Cecil, p. 2214t]