Ronan Kelly
Retired 2020
Re: Pakistan: Doctor dies of Crimean-Congo haemorrhagic fever after treating ill patient - possibly 10 deaths total
Date: Sat 9 Oct 2010
From: Dr S. R. Kakar [edited]
<kakarr@pak.emro.who.int>
Re: CCHF in Pakistan
--------------------
Dear colleagues,
To set the record straight [with regard to the incidence of
Crimean-Congo hemorrhagic fever (CCHF) in Pakistan], one must have a
report directly from the NIH or WHO in Islamabad. I really cannot
understand how hospital staff can report to journalists and their
information is so skewed. In the past 2 months, there are only *3*
confirmed cases of CCHF outside of Baluchistan as noted below. We
will look into the 5 new suspected cases at HFH [Holy Family
Hospital, Rawalpindi], but there have not been 27 confirmed CCHF
cases from HFH at any time. NIH [The National Institute of Health] is
the only lab with CCHF reagents and these are procured from CDC
[Centers for Disease Control and Prevention] Atlanta.
It may be noted that due to the October convergence of seasonality
peaks of 3 different fever diseases, falciparum malaria, dengue fever
(DF and DHF), and Crimean-Congo hemorrhagic fever, the Pakistan
Disease Early Warning System (DEWS) is receiving high number of fever
disease alerts in addition to the Acute Watery Diarrhoea (AWD) alerts.
Crimean-Congo Hemorrhagic Fever (CCHF)
--------------------------------------
In Pakistan, the incidence of CCHF peaks in June and October but
cases occur throughout the year. Since 15 Sep 2010, 3 cases of CCHF
have been confirmed outside the endemic area of Baluchistan and 2 have died.
1. Medical doctor (38-year-old male) from Mansehra, working in
Abbotabad and Besham, all districts of Khyber Pakhtunkhwa [formerly
North West Frontier province], died on 23 Sep 2010 in Abbotabad of
brain hemorrhage, confirmed CCHF positive. Exposure to virus is not
known. 14 relatives and contacts (some having fever) have tested
negative to CCHF and Dengue fever. The doctor has been named for a
citation from the Ministry of Health for sacrificing his life in the
line of duty.
2. 30-year-old male from Kahuta Tehsil, Rawalpindi District, Punjab,
hospitalized at Holy Family Hospital (HFH), died on 28 Sep 2010.
Exposure to virus is not known.
3. 35-year-old female from Attock, Punjab, hospitalized at HFH and
transferred to Shifa, Islamabad, surviving, discharged 23 Sep 2010.
Onset of fever 8 Sep 2010. Presumed exposure as keeper of buffalo and
cows in the home. District Health Office took initiative to monitor
the family for fever for 14 days and no family members became ill.
Further, they treated the family livestock appropriately with acaricide.
In addition, 4 female doctors, 3 nurses and a ward boy who work at
HFH have tested positive for CCHF. They had some type of exposure to
the 2 above cases (#2 and #3) but no clear-cut exposure to blood, and
none have had high fever or low platelets, so we are requesting
review of this result [by a] virologist. Nevertheless, the NIH sent a
team who discussed infection control with the chiefs of services and
they are taking it seriously.
Quetta [the capital of Baluchistan province] has experienced the
usual outbreaks of CCHF this year [2010] peaking in June and
September but we have so far not been able to get a report from them.
We expect that, similar to every year since 2000, they have
experienced more than 50 cases with less than 10 percent deaths. They
have promised a full report tomorrow.
Response:
---------
Guidelines for CCHF management have been distributed both to Ministry
and Health Cluster stakeholders and are posted on both NIH and WHOPAK websites.
Specific measures to reduce the risk of transmission from ticks will
be undertaken by Ministry of Agriculture and Livestock with FAO
support while measures to prevent nosocomial infection will be
promoted by the Ministry of Health.
General supportive therapy is the mainstay of patient management in
CCHF. Intensive monitoring to guide volume and blood component
replacement is required. The antiviral drug ribavirin has been used
in treatment of established CCHF infection with apparent benefit.
Both oral and intravenous formulations seem to be effective.
When patients with CCHF are admitted to hospital, there is a risk of
nosocomial spread of infection. In the past, serious outbreaks have
occurred in this way and it is imperative that adequate infection
control measures be observed to prevent this disastrous outcome.
Patients with suspected or confirmed CCHF should be isolated and
cared for using barrier nursing techniques. Specimens of blood or
tissues taken for diagnostic purposes should be collected and handled
using universal precautions. Sharps (needles and other penetrating
surgical instruments) and body wastes should be safely disposed of
using appropriate decontamination procedures.
Health care workers are at risk of acquiring infection from sharps
injuries during surgical procedures and, in the past, infection has
been transmitted to surgeons operating on patients to determine the
cause of the abdominal symptoms in the early stages of (at that
moment undiagnosed) infection. Health care workers who have had
contact with tissue or blood from patients with suspected or
confirmed CCHF should be followed up with daily temperature and
symptom monitoring for at least 14 days after the putative exposure.
There is no safe and effective vaccine widely available for human
use. The tick vectors are numerous and widespread and tick control
with acaricides (chemicals intended to kill ticks) is only a
realistic option for well-managed livestock production facilities.
Persons living in endemic areas should use personal protective
measures that include avoidance of areas where tick vectors are
abundant and, when they are active (spring to autumn); regular
examination of clothing and skin for ticks, and their removal; and
use of repellents.
Persons who work with livestock or other animals in the endemic areas
can take practical measures to protect themselves. These include the
use of repellents on the skin (e.g., DEET) and clothing (e.g.,
permethrin) and wearing gloves or other protective clothing to
prevent skin contact with infected tissue or blood.
Notably in Pakistan most of the population are directly exposed to
livestock during Eid ul Adha, which falls in mid-November this year.
A media campaign will be undertaken to inform people how to protect
themselves from CCHF infection.
--
Dr S. R. Kakar,
Senior Epidemiologist,
World Health Organization,
Islamabad
Program Manager for the Disease Early Warning System
<kakarr@pak.emro.who.int>
[ProMED-mail is indebted to Dr. Kakar for sending us this statement
regarding the current incidence of CCHF in Pakistan which refutes
some erroneous information published in the Pakistani press and
relayed previously in good faith by ProMED-mail.
Apart from numerous presumptive seasonal cases in Baluchistan (not
mentioned in the national press or in ProMED-mail), there have only
been 3 confirmed cases elsewhere in Pakistan. These are described in
detail above, together with the nosocomial infections reported to
have occurred in the Holy Family Hospital Rawpindi (and about which
there is some uncertainty).
The HealthMap/ProMED-mail interactive map of Pakistan can be accessed at:
<http://healthmap.org/r/00tj>. - Mod.CP]
[see also:
Crimean-Congo hem. fever - Pakistan (06): (PB) 20101008.3660
Crimean-Congo hem. fever - Pakistan (05): (NW) 20101003.3579
Crimean-Congo hem. fever - Pakistan (04): (PB) 20101001.3563
Crimean-Congo hem. fever - Pakistan (03): (PB) nosocomial 20100930.3547
Crimean-Congo hem. fever - Pakistan (03): (PB) 20100923.3440
Crimean- Congo hem. fever - Pakistan (02): (KI) 20100917.3372
Crimean-Congo hem. fever - Pakistan ex Afghanistan: RFI 20100629.2161]
...................cp/ejp/dk
http://promedmail.org/pls/apex/f?p=..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1010,85235
Date: Sat 9 Oct 2010
From: Dr S. R. Kakar [edited]
<kakarr@pak.emro.who.int>
Re: CCHF in Pakistan
--------------------
Dear colleagues,
To set the record straight [with regard to the incidence of
Crimean-Congo hemorrhagic fever (CCHF) in Pakistan], one must have a
report directly from the NIH or WHO in Islamabad. I really cannot
understand how hospital staff can report to journalists and their
information is so skewed. In the past 2 months, there are only *3*
confirmed cases of CCHF outside of Baluchistan as noted below. We
will look into the 5 new suspected cases at HFH [Holy Family
Hospital, Rawalpindi], but there have not been 27 confirmed CCHF
cases from HFH at any time. NIH [The National Institute of Health] is
the only lab with CCHF reagents and these are procured from CDC
[Centers for Disease Control and Prevention] Atlanta.
It may be noted that due to the October convergence of seasonality
peaks of 3 different fever diseases, falciparum malaria, dengue fever
(DF and DHF), and Crimean-Congo hemorrhagic fever, the Pakistan
Disease Early Warning System (DEWS) is receiving high number of fever
disease alerts in addition to the Acute Watery Diarrhoea (AWD) alerts.
Crimean-Congo Hemorrhagic Fever (CCHF)
--------------------------------------
In Pakistan, the incidence of CCHF peaks in June and October but
cases occur throughout the year. Since 15 Sep 2010, 3 cases of CCHF
have been confirmed outside the endemic area of Baluchistan and 2 have died.
1. Medical doctor (38-year-old male) from Mansehra, working in
Abbotabad and Besham, all districts of Khyber Pakhtunkhwa [formerly
North West Frontier province], died on 23 Sep 2010 in Abbotabad of
brain hemorrhage, confirmed CCHF positive. Exposure to virus is not
known. 14 relatives and contacts (some having fever) have tested
negative to CCHF and Dengue fever. The doctor has been named for a
citation from the Ministry of Health for sacrificing his life in the
line of duty.
2. 30-year-old male from Kahuta Tehsil, Rawalpindi District, Punjab,
hospitalized at Holy Family Hospital (HFH), died on 28 Sep 2010.
Exposure to virus is not known.
3. 35-year-old female from Attock, Punjab, hospitalized at HFH and
transferred to Shifa, Islamabad, surviving, discharged 23 Sep 2010.
Onset of fever 8 Sep 2010. Presumed exposure as keeper of buffalo and
cows in the home. District Health Office took initiative to monitor
the family for fever for 14 days and no family members became ill.
Further, they treated the family livestock appropriately with acaricide.
In addition, 4 female doctors, 3 nurses and a ward boy who work at
HFH have tested positive for CCHF. They had some type of exposure to
the 2 above cases (#2 and #3) but no clear-cut exposure to blood, and
none have had high fever or low platelets, so we are requesting
review of this result [by a] virologist. Nevertheless, the NIH sent a
team who discussed infection control with the chiefs of services and
they are taking it seriously.
Quetta [the capital of Baluchistan province] has experienced the
usual outbreaks of CCHF this year [2010] peaking in June and
September but we have so far not been able to get a report from them.
We expect that, similar to every year since 2000, they have
experienced more than 50 cases with less than 10 percent deaths. They
have promised a full report tomorrow.
Response:
---------
Guidelines for CCHF management have been distributed both to Ministry
and Health Cluster stakeholders and are posted on both NIH and WHOPAK websites.
Specific measures to reduce the risk of transmission from ticks will
be undertaken by Ministry of Agriculture and Livestock with FAO
support while measures to prevent nosocomial infection will be
promoted by the Ministry of Health.
General supportive therapy is the mainstay of patient management in
CCHF. Intensive monitoring to guide volume and blood component
replacement is required. The antiviral drug ribavirin has been used
in treatment of established CCHF infection with apparent benefit.
Both oral and intravenous formulations seem to be effective.
When patients with CCHF are admitted to hospital, there is a risk of
nosocomial spread of infection. In the past, serious outbreaks have
occurred in this way and it is imperative that adequate infection
control measures be observed to prevent this disastrous outcome.
Patients with suspected or confirmed CCHF should be isolated and
cared for using barrier nursing techniques. Specimens of blood or
tissues taken for diagnostic purposes should be collected and handled
using universal precautions. Sharps (needles and other penetrating
surgical instruments) and body wastes should be safely disposed of
using appropriate decontamination procedures.
Health care workers are at risk of acquiring infection from sharps
injuries during surgical procedures and, in the past, infection has
been transmitted to surgeons operating on patients to determine the
cause of the abdominal symptoms in the early stages of (at that
moment undiagnosed) infection. Health care workers who have had
contact with tissue or blood from patients with suspected or
confirmed CCHF should be followed up with daily temperature and
symptom monitoring for at least 14 days after the putative exposure.
There is no safe and effective vaccine widely available for human
use. The tick vectors are numerous and widespread and tick control
with acaricides (chemicals intended to kill ticks) is only a
realistic option for well-managed livestock production facilities.
Persons living in endemic areas should use personal protective
measures that include avoidance of areas where tick vectors are
abundant and, when they are active (spring to autumn); regular
examination of clothing and skin for ticks, and their removal; and
use of repellents.
Persons who work with livestock or other animals in the endemic areas
can take practical measures to protect themselves. These include the
use of repellents on the skin (e.g., DEET) and clothing (e.g.,
permethrin) and wearing gloves or other protective clothing to
prevent skin contact with infected tissue or blood.
Notably in Pakistan most of the population are directly exposed to
livestock during Eid ul Adha, which falls in mid-November this year.
A media campaign will be undertaken to inform people how to protect
themselves from CCHF infection.
--
Dr S. R. Kakar,
Senior Epidemiologist,
World Health Organization,
Islamabad
Program Manager for the Disease Early Warning System
<kakarr@pak.emro.who.int>
[ProMED-mail is indebted to Dr. Kakar for sending us this statement
regarding the current incidence of CCHF in Pakistan which refutes
some erroneous information published in the Pakistani press and
relayed previously in good faith by ProMED-mail.
Apart from numerous presumptive seasonal cases in Baluchistan (not
mentioned in the national press or in ProMED-mail), there have only
been 3 confirmed cases elsewhere in Pakistan. These are described in
detail above, together with the nosocomial infections reported to
have occurred in the Holy Family Hospital Rawpindi (and about which
there is some uncertainty).
The HealthMap/ProMED-mail interactive map of Pakistan can be accessed at:
<http://healthmap.org/r/00tj>. - Mod.CP]
[see also:
Crimean-Congo hem. fever - Pakistan (06): (PB) 20101008.3660
Crimean-Congo hem. fever - Pakistan (05): (NW) 20101003.3579
Crimean-Congo hem. fever - Pakistan (04): (PB) 20101001.3563
Crimean-Congo hem. fever - Pakistan (03): (PB) nosocomial 20100930.3547
Crimean-Congo hem. fever - Pakistan (03): (PB) 20100923.3440
Crimean- Congo hem. fever - Pakistan (02): (KI) 20100917.3372
Crimean-Congo hem. fever - Pakistan ex Afghanistan: RFI 20100629.2161]
...................cp/ejp/dk
http://promedmail.org/pls/apex/f?p=..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1010,85235