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Description of First ever outbreak of Crimean Congo Haemorrgic Fever in Human settings in Gujarat-India
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An Epidemiological investigation of a multisource outbreak of
Crimean-Congo hemorrhagic feverin Gujarat
Dr. Sudhir Gandhi Director SIHFW & Deputy Director (Epidemic)
Gandhinagar
Background • Two deaths with unusual presentation
were reported on Jan 18, 2011, by aShalby Hospital, Ahmedabad.
Objectives • To identify the etiological agent, source of
outbreak, and mode of transmission; • To propose a control measure based on
the outbreak investigation.
Result • A total 13 case patients of Crimean Congo
Hemorrhagic Fever were identified out of which9 are positive for CCHF virus, 2 are Negative forCCHF virus and in 2 instances we are not ableto take samples because of early deaths. Amongthis 13 cases 30.76 mortality rate was noted.Cases were reported in middle age group only.Environmental investigation also confirmed thepresence of CCHF virus in Ticks.
Likely Sources of Infection• Indigenous:
• Looking to the seropositivity in the other parts of the countryreported in early 70’s in the southern states of the country theinfection might be prevalent in Gujarat also because similarAgro-climatic conditions and abundant Tick population have beendemonstrated during the field investigation
• Trans border transmission: via cattle trading across theborder of Pakistan-Kutchh-Banaskantha-Ahmedbad Rural
• International source: Shalby hospital is well known for Jointreplacement surgeries and medical tourism there is a possibilityof a sero-positive case being admitted in the Shailby Hospitalduring that period who might have spread the CCHF infection toDr Gagan Sanke and other Nursing Paramedics due to anobvious lapse in Biosafety meassures in the Hospital settings
• Crimean-Congo hemorrhagic fever (CCHF) is caused byinfection with a tick-borne virus (Nairovirus) in the familyBunyaviridae.
• The disease was first characterized in the Crimea in1944 and given the name Crimean hemorrhagic fever. Itwas then later recognized in 1969 as the cause of illnessin the Congo, thus resulting in the current name of thedisease.
General Details of CCHF
Spread of Disease • Ixodid (hard) ticks, especially those of the genus,
Hyalomma, are both a reservoir and a vector for theCCHF virus.
• Numerous wild and domestic animals, such as cattle,goats, sheep and hares, serve as amplifying hosts forthe virus.
• Transmission to humans occurs through Hyalomma .Contact with infected animal blood or ticks.
• CCHF can be transmitted from one infected human toanother by contact with infectious blood or body fluids.
• Documented spread of CCHF has also occurred inhospitals due to improper sterilization of medicalequipment, reuse of injection needles, andcontamination of medical supplies
Signs & Symptoms of CCHF • Headache• Back Pain • Stomach Pain • Red Eyes• Red Throat• Petechiae on other part of
body• Jaundice• Severe Bruising• Severe Nosebleeds
• High Grade Fever >=1020
F.
• Joint Pain• Vomiting• Petechiae (Red Spots) on
the Palate• A Flushed Face• Changes in mood and
Sensory perception • Uncontrolled bleeding at
Injection sites
Case Definition Suspect case• A patient with abrupt onset of high fever >38.5°C and
one of the following symptoms: severe headache, myalgias, nausea, vomiting, and/or diarrhoea
AND• History of tick bite within 14 days prior to the onset of
symptoms; or • History of contact with tissues, blood, or other biological
fluids from a possibly infected animal (e.g., abattoir workers, livestock owners, veterinarians) within 14 days prior the onset of symptoms; or
• Healthcare workers in healthcare facilities, with a history of exposure to a suspect, probable, or laboratory-confirmed CCHF case, within 14 days prior to the onset of symptoms
Probable case• A probable CCHF case is defined as a suspected CCHF
case fulfilling in addition the following criteria:• Thrombocytopenia < 50,000/cmm
AND• Two of the following hemorrhagic manifestations:
hematoma at an injection site, petechiae, purpuric rash, rhinorrhagia, hematemesis, hemoptysis, gastrointestinal haemorrhage, gingival haemorrhage, or any other hemorrhagic manifestation in the absence of any known precipitating factor for hemorrhagic manifestation
Confirmed case• A confirmed CCHF case is defined as a case that fulfils
the criteria for probable CCHF and in addition is laboratory-confirmed with one of the following assays:
• Detection by ELISA or IFA of specific IgM antibodies against CCHF virus or a 4-fold increase in specific IgG antibodies against CCHF virus in two specimens collected in the acute and convalescence phases
• Detection by RT-PCR of CCHF virus genome in a clinical specimen confirmed by sequencing of the PCR product
• CCHF virus isolation
Definition, monitoring and Laboratory testing for contacts of CCHF cases.
Definition of “contact” Contacts include: family, neighborhood and
health care facility contactMonitoring of
contacts• All contacts should be self monitored for twice daily
for any clinical symptoms (such as fever, muscular pain or bleeding) 14 days (maximum) from the day of last contact with the patient or other source of infection.
• In case of onset of any symptom, he/ she should immediately report to the nearest health facility.
Testing bloodfor CCHF • Appropriate laboratory testing is
recommended in persons meeting the case definition.
• Diagnosis– Laboratory diagnosis of CCHF can be made by finding a positive
serological test result, evidence of viral antigen in tissue byimmunohistochemical staining and microscopic examination, oridentification of viral RNA sequence in blood or tissue, in apatient with a clinical history compatible with CCHF.
• Fatality Rate – 9 to 50%
• Treatment – Maintaining fluid and electrolyte balance in body.– Oxygen– Antibiotics– Antiviral drug- Ribavirine
Who is at risk for the disease? • Animal herders, livestock workers• Workers in slaughter houses • Veterinary officers • Health care workers are at risk of infection through unprotected
contact with infectious blood and body fluids How is the disease prevented? • Agricultural workers and others working with animals should use insect
repellent on exposed skin and clothing• Insect repellants containing DEET (N, N-diethyl- m- toluamide) are the most
effective against ticks. • Wearing gloves and other protective clothing is recommended. • Individuals should also avoid contact with the blood and body fluids of
livestock or humans who show symptoms of infection • It is important for health care workers to use proper infection control
precautions to prevent occupational exposure
Dead body disposal :
– Use rubber gloves or double surgical gloves for handling dead body. The persons handling the dead body in hospitals should also wear mask/ PPE.
– Spray dead body with 1:10 liquid bleach. Wrap with a winding sheet. Spray the winding sheet with bleach solution.
– Place the wrapped and bleached body in plastic bag. Seal with adhesive tape and transport
– Disinfect ambulance / transport vehicle.
Kismpa,Vadnagar
Kolat,Sanand
Affected Area
Adasar,Kheda
Sr.No. Case Details Date of Onset
SymptonsLab Test
ResultDate of Expired Epidemiological linkage
1Aminaben Rehmanbhai Momin32 Year FemaleKolat Village(A'Bad)
22/12/2011 Sample Not Taken 03-01-2011
Consider as Index case residing at village where animals and ticks found positive for CCHF virus
2Dr.Gagan Senke42 Year MaleA'bad city Hospital staff
06-01-2011 Sample Not Taken 13-01-2011 Treating Doctor of Aminaben
3K Asha John25 Year FemaleA'bad city Hospital staff
12-01-2011 Positive 18-01-2011 Treating Nurse of Aminaben
4Lima24 Year FemaleA'bad city Hospital staff
19-01-2011 PositiveAcquired infection either contacts with or during treatment of diseased Dr Gagan and Ashaben
5Prashant Joy23 Year Male A'bad city Hospital staff
21-01-2011 PositiveAcquired infection either contacts with or during treatment of diseased Dr Gagan and Ashaben
6Yohanan John25 Year Male A'bad city Hospital staff
21-01-2011 PositiveAcquired infection either contacts with or during treatment of diseased Dr Gagan and Ashaben
7Rehman Hussain Momin32 Year MaleKolat Village(A'Bad)
12-01-2011 Positive Husband of Aminaben may acquired infection during conatact of Aminaben
8Husen Rasoolbhai Momin27 Year MaleKolat Village(A'Bad)
16-01-2011 Negative
9Devasya V.C.27 Year Male A'bad city Hospital staff
18-01-2011 Negative
10Dr.Sabbirali G. Umatiya25 Year MaleA'bad city Hospital staff
26-01-2011 Positive 31-01-2011
Epidemiological linkages could not be clearly established with kolat village victims. But unconfirmed information suggested that he was frequently visiting shalby hospital and he had contact with deceased Dr Gagan Sanke
11Javed Mohmad Momin28 Year MaleKismpa Village(Mehsana)
No Symptoms Positive Contact of Dr.Sabbir Ali
12Nafijaben Gulambhai Nagalpara22 Year FemaleKismpa Village(Mehsana)
No Symptoms Positive Contact of Dr.Sabbir Ali
13Kanjibhai Virabhai Chavda50 Year Male Adasar Village(Kheda)
02-02-2011 PositiveEpidemiological linkage of Kanjibhai could not be established with previously listed any cases
Epidemiological Linkage in Cases
Action Taken • Intensive surveillance has been started through health
staff in Kolat village and nearby villages in radius of 5 kmon the same day to search cases of having same signsymptoms. Same type of activity is also carried out inAhmedabad city, Kesimpa and Adasar also. Feversurveillance has been carried out in contacts.
• As ticks and animals aremain reason forspreading this disease,Animal Husbandrydepartment is involved incontrol measures from18/1/2011
Action Taken • Sero-Surveillance is
also carried out byAnimal Husbandrydepartment amonganimals and tickssample taken forinvestigation
• Insecticide hasbeen sprayed onmore than 13000animals
Action Taken • IMA was also sensitized for this disease, they published
information regarding this issue in their bulletin.• Enough stock of Anti viral drug Ribavirine is available in
state and another can be procured from centralgovernment if required.
• Commissioner (Health) is reviewing the situation ofoutbreak on regular basis. As infection can be spread tohospital staff also, intensive steps are taken for infectioncontrol practices and biomedical waste disposal.
• Inter departmental meeting was held On 24/1/11 underchairmanship of Hon'ble Health Minister in presence ofHon'ble ministers of Rural Development, AnimalHusbandry and Urban Development, Chief Secretary andSecretaries from concerned department for review ofsituation and planning of activities to control of thisdisease.
• Intensive IEC has been carried out to contain panic incommunity
Crimean Congo Hemorrhagic Fever Report-Gujarat State
31/3/2011 Sr.No Details Daily Progresive Remarks
1 Suspected Case 0 132 Death 0 43 Sample Taken
3a Human 0 301 Examined 0 269 Positive 0 9
3b Animal 0 496 Examined 0 309 Positive 0 4
3c Ticks 0 496 Examined 0 78Positive 0 8
4 Number of Team Working ineffected Area
24
5 Surveillance Report5a Surveyed Houses5b Surveyed Population5c Contact Person 0 2875d Sprey of Deltameprine on
Animal0 13557
5e Residual Sprey onshed/house
0 263
840037589
Future Plans• Strengthening of Waste disposal• Maintaining of cleanliness• Prevention of transmission of virus from animal
to human by tick control activity with intensivespray of acericide in affected area
• Intensive fever surveillance in affected area• Isolation ward for patients• Proper infection control practices and
Biomedical waste disposal• Intensive IEC
Recommendations • Intensive tick control measures have to be taken by
spraying acericide drug on all animals in affected andneighborhood villages.
• All animals should be covered under effectivesupervision of Animal Husbandry department;otherwise spreading of CCHF virus will be severe infuture.
• Insecticide have to be sprayed intensively in all breakson floor and walls in cattle shades
• Treatment and spraying with drug has to be repeatedafter One month.
• To contain the spread of the disease the admission ofthe patients should be in identified hospitals only.
Recommendations • Health care staff in the hospitals should be educated
with emphasis on protective measures.• Surveillance among Hospital contacts should be
strengthened at hospital setting.• Biomedical waste management at the hospitals should
be strengthened.• Strengthening of health education about causation,
transmission and prevention of disease.• State wide sero surveillance in animals to identify
prevalence of disease in Gujarat.
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