Crimean-Congo hemorrhagic fever

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ilan Dock, B.S.

Overview

Crimean-Congo hemorrhagic fever (CCHF) is a widespread tick-borne viral disease, a zoonosis of domestic animals and wild animals, that may affect humans. The pathogenic virus, especially common in East and West Africa, is a member of the Bunyaviridae family of RNA viruses. Clinical disease is rare in the majority of infected mammals, but commonly severe in infected humans, with a 30% mortality rate. Outbreaks of illness are usually attributed to handling the bodily fluids of infected animals or people.

Differentiating Crimean-Congo Hemorrhagic Fever from other Diseases

Crimean-Congo hemorrhagic fever should be differentiated from the following diseases:

Disease Organism Vector Symptoms
Bacterial Infection
Borreliosis (Lyme Disease) [1] Borrelia burgdorferi sensu lato complex and B. mayonii I. scapularis, I. pacificus, I. ricinus, and I. persulcatus Erythema migrans, flu-like illness(fatigue, fever), Lyme arthritis, neuroborreliosis, and carditis.
Relapsing Fever [2] Tick-borne relapsing fever (TBRF): Borrelia duttoni, Borrelia hermsii, and Borrelia parkerii Ornithodoros species Consistently documented high fevers, flu-like illness, headaches, muscular soreness or joint pain, altered mental status, painful urination, rash, and rigors.
Louse-borne relapsing fever (LBRF) : Borrelia recurrentis Pediculus humanus
Typhus (Rickettsia)
Rocky Mountain Spotted Fever Rickettsia rickettsii Dermacentor variabilis, Dermacentor andersoni Fever, altered mental status, myalgia, rash, and headaches.
Helvetica Spotted Fever [3] Rickettsia helvetica Ixodes ricinus Rash: spotted, red dots. Respiratory symptoms (dyspnea, cough), muscle pain, and headaches.
Ehrlichiosis (Anaplasmosis) [4] Ehrlichia chaffeensis, Ehrlichia ewingii Amblyomma americanum, Ixodes scapularis Fever, headache, chills, malaise, muscle pain, nausea, confusion, conjunctivitis, or rash (60% in children and 30% in adults).
Tularemia [5] Francisella tularensis Dermacentor andersoni, Dermacentor variabilis Ulceroglandular, glandular, oculoglandular, oroglandular, pneumonic, typhoidal.
Viral Infection
Tick-borne meningoencephalitis [6] TBEV virus Ixodes scapularis, I. ricinus, I. persulcatus Early Phase: Non-specific symptoms including fever, malaise, anorexia, muscle pains, headaches, nausea, and vomiting. Second Phase: Meningitis symptoms, headache, stiff neck, encephalitis, drowsiness, sensory disturbances, and potential paralysis.
Colorado Tick Fever [7] CTF virus Dermacentor andersoni Common symptoms include fever, chills, headache, body aches, and lethargy. Other symptoms associated with the disease include sore throat, abdominal pain, vomiting, and a skin rash. A biphasic fever is a hallmark of Colorado Tick Fever and presents in nearly 50% of infected patients.
Crimean-Congo Hemorrhagic Fever CCHF virus Hyalomma marginatum, Rhipicephalus bursa Initially infected patients will likely feel a few of the following symptoms: headache, high fever, back and joint pain, stomach pain, vomiting, flushed face, red throat petechiae of the palate, and potentially changes in mood as well as sensory perception.
Protozoan Infection
Babesiosis [8] Babesia microti, Babesia divergens, Babesia equi Ixodes scapularis, I. pacificus Non-specific flu-like symptoms.

Epidemiology

  • Sporadic infection of people is usually caused by Hyalomma tick bite.
  • Clusters of illness typically appear after people treat, butcher, or eat infected livestock. Particularly ruminants and ostriches.
  • Outbreaks have occurred in clinical facilities where health workers have been exposed to infected blood and fomites.
  • On July 28, 2005 authorities reported 41 cases of CCHF in Turkey's Yozgat Province, with one death.

Endemic Regions

  • Endemic areas include Asia, Eastern Europe, the Middle East, a belt across central Africa and South Africa and Madagascar.
  • Main environmental reservoir for the virus are small mammals (particularly European hare, Middle-African hedgehogs and multimammate rats).

Notable outbreaks

  • During the summers of 1944 and over 200 cases of an acute, hemorrhagic, febrile illness occurred in Soviet troops rescuing the harvest following the ethnic cleansing of the Crimean Tatars.
  • Virus was discovered in blood samples of patients and in the tick Hyalomma marginatum marginatum.
  • Researchers soon recognized that a similar disease had been occurring in the Central Asian Republics.

Causes

Life Cycle and Spread of Disease

General Tick Life Cycle [9]

This image displays an example of the tick lifecycle, based on stages and the months that they are most likely to occur during.
  • A tick's life cycle is composed of four stages: hatching (egg), nymph (six legged), nymph (eight legged), and an adult.
  • Ticks require blood meal to survive through their life cycle.
  • Hosts for tick blood meals include mammals, birds, reptiles, and amphibians. Ticks will most likely transfer between different hosts during the different stages of their life cycle.
  • Humans are most often targeted during the nymph and adult stages of the life cycle.
  • Life cycle is also dependent on seasonal variation.
  • Ticks will go from eggs to larva during the summer months, infecting bird or rodent host during the larval stage.
  • Larva will infect the host from the summer until the following spring, at which point they will progress into the nymph stage.
  • During the nymph stage, a tick will most likely seek a mammal host (including humans).
  • A nymph will remain with the selected host until the following fall at which point it will progress into an adult.
  • As an adult, a tick will feed on a mammalian host. However unlike previous stages, ticks will prefer larger mammals over rodents.
  • The average tick life cycle requires three years for completion.
    • Different species will undergo certain variations within their individual life cycles.



Spread of Tick-borne Disease

  • Ticks require blood meals in order to progress through their life cycles.
  • The average tick requires 10 minutes to 2 hours when preparing a blood meal.
  • Once feeding, releases anesthetic properties into its host, via its saliva.
  • A feeding tube enters the host followed by an adhesive-like substance, attaching the tick to the host during the blood meal.
  • A tick will feed for several days, feeding on the host blood and ingesting the host's pathogens.
  • Once feeding is completed, the tick will seek a new host and transfer any pathogens during the next feeding process. [9]

Virology

  • Nairovirus in the family of Bunyaviridae.

Transmission

  • Ixodid ticks, of the Hyalomma genus, are the primary vector and reservoir of infection.
  • Human transmission occurs through human contact with infected animal or human blood and body fluids.

History and Symptoms

Isolated male patient diagnosed with Crimean-Congo hemorrhagic fever




Laboratory diagnostics

  • ELISA, RT-PCR, antibody titers, immunohistochemical staining, and virus isolation attempts are all laboratory tests to assist in the diagnosis of a potential Crimean-Congo hemorrhagic fever.
  • An ELISA may be used for diagnosis during the acute phase of infection.
  • Polymerase Chain Reaction may be used to identify viral RNA sequences in the blood or tissues collected.

Treatment

  • Treatment is primarily symptomatic and supportive, as there is no established specific treatment.
  • Ribavirin is effective in vitro[10] and has been used during outbreaks,[11] but there is no trial evidence to support its use.

Risk Factors

Endemic Areas

  • Travelling through endemic areas increase the risk of infection.
  • Endemic areas include Asia, Eastern Europe, the Middle East, a belt across central Africa and South Africa and Madagascar.

Livestock

  • Sheep, goats and cattle develop high titers of virus in blood, but tend not to fall ill.
  • Transmission may occur through unprotected contact with blood and other body fluids of an infected animal.

Occupational

  • The following individuals are at a higher risk of infection in endemic areas:
  • Livestock workers
  • Animal herders
  • Slaughterhouse workers

Prevention

Limiting tick exposure

Tuck pants into socks

It is unreasonable to assume that a person can completely eliminate activities that may result in tick exposure. Therefore, prevention measures should emphasize personal protection when exposed to natural areas where ticks are present:

  • Wear light-colored clothing which allows you to see ticks that are crawling on your clothing.
  • Tuck your pants legs into your socks so that ticks cannot crawl up the inside of your pants legs.
  • Apply repellents to discourage tick attachment. Repellents containing permethrin can be sprayed on boots and clothing, and will last for several days. Repellents containing DEET (n, n-diethyl-m-toluamide) can be applied to the skin, but will last only a few hours before reapplication is necessary. Use DEET with caution on children. Application of large amounts of DEET on children has been associated with adverse reactions.
  • Conduct a body check upon return from potentially tick-infested areas by searching your entire body for ticks. Use a hand-held or full-length mirror to view all parts of your body. Remove any tick you find on your body.
  • Parents should check their children for ticks, especially in the hair, when returning from potentially tick-infested areas.
  • Ticks may also be carried into the household on clothing and pets and only attach later, so both should be examined carefully to exclude ticks.[7]

Public health measures

  • Where mammal and tick infection is common agricultural regulations require de-ticking farm animals before transportation or delivery for slaughter.
  • Personal tick avoidance measures are recommended, such as use of insect repellents, adequate clothing and body inspection for adherent ticks.
  • When feverish patients with evidence of bleeding require resuscitation or intensive care, body substance isolation precautions should be taken.
  • The United States armed forces maintain special stocks of ribavirin to protect personnel deployed to Afghanistan and Iraq from CCHF.

External links

  • Ergönül O. (2006). "Crimean-Congo haemorrhagic fever". Lancet Infect Dis. 6: 203–214. doi:10.1016/S1473-3099(06)70435-2.
  • World Health Organization Fact Sheet

Gallery

References

  1. Lyme Disease Information for HealthCare Professionals. Centers for Disease Control and Prevention (2015). http://www.cdc.gov/lyme/healthcare/index.html Accessed on December 30, 2015
  2. Relapsing Fever Information. Centers for Disease Control and Prevention (2015). http://www.cdc.gov/relapsing-fever/ Accessed on December 30, 2015
  3. Rocky Mountain Spotted Fever Information. Centers for Disease Control and Prevention (2015). http://www.cdc.gov/rmsf/ Accessed on December 30, 2015
  4. Disease index General Information (2015). http://www.cdc.gov/parasites/babesiosis/health_professionals/index.html Accessed on December 30, 2015
  5. Rocky Mountain Spotted Fever Information. Centers for Disease Control and Prevention (2015). \http://www.cdc.gov/tularemia/index.html Accessed on December 30, 2015
  6. General Disease Information (TBE). Centers for Disease Control and Prevention (2015). http://www.cdc.gov/vhf/tbe/ Accessed on December 30, 2015
  7. 7.0 7.1 General Tick Deisease Information. Centers for Disease Control and Prevention (2015). http://www.cdc.gov/coloradotickfever/index.html Accessed on December 30, 2015
  8. Babesiosis. Centers for Disease Control and Prevention (2015). http://www.cdc.gov/parasites/babesiosis/disease.htmlAccessed December 8, 2015.
  9. 9.0 9.1 Life Cycle of Ticks that Bite Humans (2015). http://www.cdc.gov/ticks/life_cycle_and_hosts.html Accessed on December 30, 2015
  10. Watts DM, Ussery MA, Nash D, Peters CJ. (1989). "Inhibition of Crimean-Congo hemorrhagic fever viral infectivity yields in vitro by ribavirin". Am J Trop Med Hyg. 41: 581–85. PMID 2510529.
  11. Ergönül Ö, Celikbas A, Dokuzoguz B; et al. (2004). "The chacteristics of Crimean-Congo hemorrhagic fever in a recent outbreak in Turkey and the impact of oral ribavirin therapy". Clin Infect Dis. 39: 285–89. doi:10.1086/422000.
  12. 12.0 12.1 12.2 "Public Health Image Library (PHIL)".

de:Krim-Kongo-Fieber fa:تب خونریزی‌دهنده کریمه کنگو


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