Abbasi, A.

Besharat, S.

Jabbari, A.

English

Golestan University of Medical Sciences Repository

Corresspondence SOME EVIDENCES ABOUT CRIMEAN CONGO HEMORRHAGIC FEVER Ali Jabbari1, Sima Besharat2, Abdollah Abbasi3 This refers toDr. Levent Doganci’s letter published in your valuable Journal about Congo Hemorrhagic Fever (CCHF) entitled “Crimean Congo Haemorrhagic Fever as an indication for use of Ribavirin”.1 Crimean-Congo Hemorrhagic Fever is a widely distrib­uted lethal disease, worldwide.2 Human are usually infected with CCHF virus through a tick bite or close contact with viral contami­nated tissues or with blood of domestic ani­mals or of infected patients.2-4 There are a few clinical and epidemiologically re-emerging points, which need to be highlighted about this deadly viral infection. We reported a case-series about patients who suffered from CCHF in northeast of Iran (2004­2006). We saw a good clinical response to in­travenous prescription or oral form of Ribavirin at the early stages of the disease along with 1.	 Ali Jabbari MD, MPH, Golestan University of Medical Sciences, 2.	 Sima Besharat MD, Researcher, Golestan University of Medical Sciences, Golestan Research Center of Gastroenterology and Hepatology, 3.	 Abdollah Abbasi, MD, Specialist in Infectious Diseases, Faculty member of Golestan University of Medical Sciences, Golestan – Iran. Correspondence Sima Besharat (MD), Researcher, Golestan University of Medical Sciences, Golestan Research center of Gastroenterology and Hepatology, Address: 21st Edalat, Vali_e_asr Ave, Gorgan City, Golestan Province, Iran. Postal code: 49177-44563 E-mail: s_besharat_gp@yahoo.com * Received for Publication: January 5, 2008 * Accepted for Publication: January 25, 2008 high dose corticosteroids, intensive monitoring, careful attention to fluid balance, correction of electrolyte abnormalities, appropriate treat­ment of secondary infections, enough oxygen­ation, massive transfusion and hemodynamic support; depending upon the situation.4 Human cases of Crimean Congo Hemor­rhagic Fever (CCHF) have been reported from Turkey, since 2002 with increasing morbidity rate and some fatalities. CCHF can be consid­ered as an endemic lethal disease in that region.5,6 Based on our clinical experience, Ribavirin could be considered as a useful medicine for CCHF therapy in endemic regions but in the early stages of clinical process. Ribavirin was also recommended in post-exposure prophy­laxis to soldiers in Operation Desert Shield/ Storm and in Korea.7 Clinical features usually include a rapid progression characterized by hemorrhage, myalgia and fever, with 30% mortality rate and it can develop up to 50%.8 According to the clinical response and cure seen in most of the patients who were treated with antiviral agents such as Ribavirin accom­panied with corticosteroids, intensive monitor­ing and conservative therapy, it can be con­cluded that this treatment can be considered as a good treatment protocol, if prescribed at the early stages. Delay in diagnosis decreases the efficacy of treatment and aggravates the outcome of the disease. This important fact that “early ribavirin use in the beginning of illness has significant posi­tive effect on survival” has also been empha­sized in other reports.9-11 In addition, Ribavirin is a WHO recommended anti-viral for CCHF. Thus, we suggest this method of treatment as a basic treatment protocol in the early stages of CCHF.4 It should also be noted that one of the most prominent differences between Iran and Turkey and some other countries is the route of virus transmission. As Dr. Doganci pointed out in the manuscript, tick exposure and tick removal can be the main life saving protocol, Pak J Med Sci  2008  Vol. 24   No. 1     www.pjms.com.pk   187  Corresspondence while the major root of transmission is the tick bite. It is confirmed that one of the major roots of transmission is the tick bite2,3; but some other reports showed that close contact with sheep had the main role in the transmission.12 It should be kept in mind that in some special areas, like Northeast of Iran and Turkey, which sheepherding is one of the most common jobs, the route of contamination could be different. Therefore, CCHF must be considered as a job hazardous. Sheep, goats and cattle develop high titers of virus in blood, but tend not to fall ill. People who work with livestock, animal herders and slaughterhouses workers, in en­demic areas like Iran and Turkey are at risk of CCHF and must take measures for protection. Medical laboratory staffs are another high-risk group. Diagnosis of CCHF is important to pre­vent the spread of CCHF virus among the health-care workers and relatives of patients. Protection of tick exposure and appropriate tick removal has a life saving potency. We fully support the valuable advice of the author, and suggest that in low–income af­fected population who come from the farms of rural areas, CCHF can be added as an indi­cation of Ribavirin to solve this life–threaten­ing problem. In the endemic areas, ecological changes, poverty, social instability, insufficient medical equipment, and absence of standard infection control practices have contributed to increase transmission of virus.8 So; CCHF is a disease with several predisposing factors, and its outbreak constitute a threat to public health services because of increased transmission in its natural environment, in the community, and in the hospital settings. A practical advice for protection can be as following: use insect repellent on exposed skin besides wearing gloves and other protective cloths. Insect repellants containing DEET (N, N-diethyl-m-toluamide) are the most effective in warding off ticks.13 Individuals should also avoid contact with the blood and body fluids of livestock or human who show symptoms of infection.13 An inactivated, mouse-brain derived vaccine against CCHF has been developed and is used on a small scale in Eastern Europe. However, there is no safe and effective vaccine widely available for human use.13 Immune plasma has been used to treat CCHF patients, but its effects have not been studied with controls. REFERENCES 1.	 Doganci L, Tasdeler Fisgin N. Crimean Congo Haemorrhagic Fever as an indication for use of Ribavirin. Pak J Med Sci 2007;23(4):657. 2.	 World Health Organization [WHO]. Crimean-Congo haemorrhagic fever [online]. WHO information fact sheet no. 208. WHO; 2001 Nov. Available at: http:// www.who.int/mediacentre/factsheets/fs208/en/. Ac­cessed 28 Jul 2007. 3.	 Fisher-Hoch SP, McCormick JB, Swanepoel R, Van Middlekoop A, Harvey S, Kustner HG. Risk of human infections with Crimean-Congo hemorrhagic fever virus in a South African rural community. Am J Trop Med Hyg 1992;47:33745. 4.	 Jabbari A, Besharat S, Abbasi A, Moradi A, Kalavi KH. Crimean-congo hemorrhagic fever: case series from a medi­cal center in Golestan province, northeast of Iran (2004­2006). Ind J Med Sci 2006;60(8):327-9. 5.	 Gozalan A, Esen B, Fitzner J, Tapar FS, Ozkan AP, Georges-Courbot MC, et al. Crimean-Congo haemorrhagic fever cases in Turkey. Scand J Infect Dis 2007;39(4):332-6. 6.	 Ergonul O, Celikbas A, Dokuzoguz B, Eren S, Baykam N, Esener H. Characteristics of patients with Crimean-Congo hemorrhagic fever in a recent outbreak in Turkey and im­pact of oral ribavirin therapy. Clin Infect Dis 2004;39(2):284-7. 7.	 Wölfel R, Paweska JT, Petersen N, Grobbelaar AA, Leman PA, Hewson R, et al. Virus detection and monitoring of viral load in Crimean-Congo hemorrhagic fever virus pa­tients. Emerg Infect Dis. 2007; 13: [Epub ahead of print]. Available at: http://www.cdc.gov/eid/content/13/7/ 1097.htm. Accessed 28 Jul 2007. 8.	 Pierre DVM, Schnepf G, Gonzalez-Martin F, Zhenqiang BI. Crimean-Congo Hemorrhagic Fever, International Surveil­lance and Control of Crimean-Congo Hemorrhagic Fever Outbreaks, Springer Netherlands, 2007;295-303. 9.	 Whitehouse CA. Crimean-Congo hemorrhagic fever. Anti­viral Res 2004;64(3):145-60. 10.	 Jamil B, Hasan RS, Sarwari AR, Burton J, Hewson R, Clegg C. Crimean-Congo hemorrhagic fever: experience at a ter­tiary care hospital in Karachi, Pakistan. Trans R Soc Trop Med Hyg 2005;99(8):577-84. 11.	 Ergonul O. Crimean-Congo haemorrhagic fever. Lancet Infect Dis 2006;6(4):203-14. 12.	 El-Azazy OM, Scrimgeour EM. Crimean-Congo haemorrhagic fever virus infection in the western province of Saudi Arabia. Trans R Soc Trop Med Hyg 1997;91:275-8. 13.	 Centers for Disease Control and Prevention Centers for Disease Control and Prevention [CDC]. Crimean-Congo hemorrhagic fever. CDC; 2005 Aug. Available at: http:// www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/ cchf.htm. Accessed 28 Jul 2007. 188  Pak J Med Sci  2008  Vol. 24  No. 1    www.pjms.com.pk View publication stats 

Some evidences about Crimean Congo Hemorrhagic Fever

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Some evidences about Crimean Congo Hemorrhagic Fever

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