1. S H A K E R A S A D I Q G I L L
Crimean-congo hemorrhagic
fever

2. Definition
 An acute disease caused by arbovirus that can be
transmitted to humans by ticks.
 First described by 1944 in crimean peninsula
 Viral etiology was confirmed in 1945

3. Etiology
 CCHF belongs to family Bunyaviridae genus
Nairovirus (from Nairobi sheep disease virus)

4. Occurrence
 Human CCHF is known to occur in 38 countries
including
 Iraq
 Afghanistan
 Pakistan

5.  In areas of endemicity infection with CCHF found in
human and domestic animals more frequently in
cattle than in sheep and goats.

6. Risk of Exposure
 Animal herders, livestock workers, and
slaughterhouse workers in endemic areas are at risk
of CCHF.
 Healthcare workers in endemic areas handling blood
and body fluids.
 Individuals and international travellers with contact
to livestock in endemic regions may also be exposed.

7. Reservoir of infection
 Hedgehogs
 Horses
 Mouse like rodents act as reservoir

8. Hedgehogs

9. Vectors
 Ticks act as reservoir
 CCHF has been isolated from more than 30 species
of ticks including predominately Hyalomma but also
Ixodes species

10. Ticks

11.  Human infection occur in rural areas with livestock,
slaughter houses and dairy cattle as the source of
epidemic
 In Afghanistan and UAE camels introduce the CCHF
virus

12. Transmission
 Contact with ticks
 Infected livestock
 Tick sucking on a cow bruised with hand, virus can
be transmitted
 Slaughtering of animals
 Castration
 Branding of animals

13.  Support in birth
 Nosocomial infections are frequent
 Occur in patient care takers
 Aerosol transmission
 Used as biological weapon for bioterrorism

14. Clinical manifestations
 Incubation period after tick bite is 1-3 days
 Depending upon the dose IP may up to 9 days
following nosocomial exposure to viremic
blood,tissues and excreta
 Fever
 Shivering
 Maliase

15.  Irritability
 Head-limb and backaches.
 Anorexia
 Abdominal pain and nausea
 Vomiting is common
 Fever last for 5-12 days but biphasic courses are seen

16.  Skin on face and neck is red and swollen
 Conjunctiva and mucous membranes are congested
and edematous
 Petechial bleeding on the skin of entire body
 Bleeding on mucosal membranes
 Urogenital bleeding
 Case fatality is 30 -50 days

17.  Patients die with hemorrhagic shock and secondary
infections.

18. Diagnosis
 Diagnostic tests should be performed in BSL 4
 PCR
 RT-PCR
 Testing for virus specific IgM antibodies
 ELISA
 Serum neutralization

19. Differential diagnosis
 Typhoid fever
 Malaria
 Yellow fever
 Dengue

20. Therapy
 Treatment for CCHF is primarily supportive.
 Care should include careful attention to fluid balance
and correction of electrolyte abnormalities,
oxygenation and appropriate treatment of secondary
infections.
 Intensive care should be given with protective
clothing's
 Vital function must be controlled

21.  Packed red cells, platelets, clotting factors and
albumin are required for the treatment of
hemorrhagic shock.
 Ribavirin blocks viral replication can be used.
 Transport of patient with hemorrhagic fever to the
hospital in isolation quarters is not recommended.
 In critical stage the patients be attended by
experienced personal.

22. Prophylaxis
 Inactivated virus vaccine from mouse brain was
prepared in Russia
 No modern vaccine is available
 Use gloves and protective clothing while handling
infected patients and cattle
 Nosocomial infections should be prevented
 Safe handing of infected material

23.  Specimen should be inactivated before removal from
isolation ward
 Addition of detergent will reduce the virus titer
 The most dangerous manipulation is running
specimen in the centrifuge
 Infected needles and knives should be avoided

24.  Agricultural workers and others working with
animals should use insect repellent on exposed skin
and clothing.
 Insect repellents containing DEET (N, N-diethyl-m-
toluamide) are the most effective in warding off
ticks.

25. Reducing the risk of tick-to-human transmission
WHO recommendations
 wear protective clothing (long sleeves, long
trousers);
 wear light coloured clothing to allow easy
detection of ticks on the clothes;
 use approved acaricides (chemicals intended to
kill ticks) on clothing;

26.  use approved repellent on the skin and clothing;
 regularly examine clothing and skin for ticks; if
found, remove them safely;
 seek to eliminate or control tick infestations on
animals or in stables and barns; and
 avoid areas where ticks are abundant and
seasons when they are most active.

27. Reducing the risk of animal-to-human
transmission
 wear gloves and other protective clothing while
handling animals or their tissues in endemic
areas, notably during slaughtering, butchering
and culling procedures in slaughterhouses or at
home;
 quarantine animals before they enter
slaughterhouses or routinely treat animals with
pesticides two weeks prior to slaughter.

28. 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.

29. CCHF in Pakistan
 From 1 January to 9 June 2013, a total of 16
suspected cases of Crimean-Congo haemorrhagic
fever (CCHF), including six deaths (case–fatality rate
37.5%) were reported from Pakistan.
 So far, 7 of these reported cases have been
laboratory-confirmed.
 In 2012, the country faced a similar outbreak of
CCHF with 61 suspected cases, including 17 deaths
(case–fatality rate 27.8%) reported from the disease.

30.  The majority of the cases were reported from the
province of Balochistan, Sindh, Khyber
Pakhtunkhwa and Punjab.
 Crimean-Congo haemorrhagic fever is endemic in
Pakistan and cases are reported sporadically since
2000.

31. Suspected cases of CCHF reported in Pakistan 2000-2010
Year Case Death Case fatality
2000-2002 191 59 26.2
2003-2006 328 42 12.8
2010 29 3 4.9
2012 61 17 27.8

32. End