Crimean-Congo Hemorrhagic Fever Virus (CCHFV): A virus with a political tinge!

Crimean Congo hemorrhagic infection is a neglected viral infection in Pakistan. Our general public is oblivious of this infection. According to World Health Organization cases are reported throughout the year in endemic Pakistan. From 2012-2014, 200 cases were reported with 45 deaths (WHO, EMRO, Surveillance, forecasting and response, Crimean-Congo haemorrhagic fever in Pakistan, 2015). Last year more than 24 deaths were reported (PRO/AH/EDR, Crimean-Congo hem. fever - Pakistan (19), 20151106.3770944, Nov., 2015). The first case of 2016 was reported in March and till now more than seven cases have been reported from our region. A new case has emerged from Rawalpindi area last week. The patient was a butcher by profession. This toll will rise since this infection rate increases from June to October. This may be due to the increased number of cattle reared for Eid ul Azha during this time period.

Hard ticks (pissu), especially Hyalomma ticks, act as both reservoir and vector of this virus. These ticks infest cattle, sheep, camels, goats or hares, and from here human can make contact with this virus. Virus is essentially spread through tick bite while human to human transmission is rare. Humans can get this virus through infected blood or body fluids of infected patients. Although the transmission routes of this virus are not many yet it is an important infection to control because of high death rate during an epidemic season. Death rates can increase from 9-50%. With no vaccine available for humans or animals, treatment is basically of supportive nature where fluid balance is critical to maintain.  Ribavirin can be used alongside controlling any secondary infections.  

Hard Ticks. Their four morphological stages; (left to right) larva, nymph, adult male and female. Beat 'em!

Taken from: http://itg.author-e.eu/Generated/pubx/173/ectoparasites/ticks.htm

Documented spread of CCHF has also occurred in hospitals due to improper sterilization of medical equipment, reuse of injection needles, and contamination of medical supplies. This point brings to distressing news for me. In last week of July, Dr. Saghir Sameja died after he contacted CCHV from a patient while operating on her. Another doctor, Dr. Omar also contacted this virus. Their patient, the nurse, was said to be a wife of a cattle trader. The doctors might have caught this virus while they came in contact with the infected blood of the patient.  

There is an interesting history in naming of this virus. Russian authorities deployed their soldiers to harvest crops instead of the peasants in Crimea in 1944. Here some 200 Russian soldiers contacted the “Crimean Hemorrhagic Fever” named after the place due to tick bites while staying in open fields. After many failed attempts, this virus was isolated in a renowned Russian virologist’s lab in 1967. While almost a decade ago a virus was isolated from a child in Democratic Republic of Congo in 1956 and hence named Congo Virus. Now the virus from 1967 was sent to Rockefeller Foundation Virus Laboratory (RFVL) in New York and was found close to Congo virus. So the naming of this virus started in 1969 by The International Committee on Taxonomy of Viruses [ICTV] and proposed the name "Congo-Crimean hemorrhagic fever virus", but the Russians kept insisting on "Crimean-Congo hemorrhagic fever virus". After a long diplomatic standstill, and against all principles of scientific nomenclature based on priority of publication and of virus isolation, the “Crimean-Congo hemorrhagic fever virus” was finally adopted as the official name in 1973 (PRO/AH, Crimean-Congo hem. fever: background, 20150309.3217736, 2015).

Pakistan is an agrarian economy where cattle are used for dairy farming and livestock. Also during Eid-ul-Azha holidays cases of this infection increase in number. It is a custom here to keep the animal for few days or even months before the event and then sacrifice the animal in ones house by either men of the family or butchers. Sacrificial animals are reared throughout the year in villages or small cities and then they are taken to different parts of the country and sold. Due to our societal customs, there is an increased contact between the animal and the human. Especially children stay close to sacrificial animals and play and feed them. This causes transmission of CCHFV to humans and many cases are reported during the time of Eid-ul-Azha.

There is a lack of knowledge and practices to keep animals safe from getting infested by ticks. Because sacrificial animals are traded between countries hence the chance of spread of this infection among countries is very likely. There should be stricter practices to treat animals at entry points both at inter and intra-country levels. Medical practitioners require more training and protection to remain safe. With a growing population, this country requires preplanning and intensive surveillance to control any epidemic that may become a burden on economy as well as on people. Advisor to CM Punjab on Health, Khawaja Salman Rafique has constituted a team to look into this matter. Let us see what measures will be taken to control any further spread of this virus.

PRECAUTIONS:

Here are few points that should be followed by general public.

• Wear full clothes while going to animal markets for purchase of cattle.
• Try not to use baggy clothes while coming in contact with the animals.
• Keep looking for any ticks around you.
• Use tick repellents like DEET, Autan or permithrin before handling cattle or going to open grassy places.
• Also use these repellents while going on hiking etc and try not to walk on long grass.
• Cattle must be treated with tick repellents to control any spread of ticks.
• This may seem gruesome but it is important to treat the body of dead patient with diluted bleach. Also, thick gloves must be used in washing the body so as to minimize any body fluid contact with the persons handling it.
•  Any contact with the body fluid of suspected patients must be avoided.
• And our medical practitioners need extra care while handling any suspected patient of hemorrhagic fever.

Hopefully this virus will not spread and our Eid ul Azha time period will remain safe from it!