Crimean-Congo Hemorrhagic Fever Guide

Crimean-Congo
hemorrhagic fever
Dr. Sunil Panjwani, M.D.(Medicine)
Associate Professor(Medicine)
26 August 2014 Medical CDr. oSunill Planejwgani, e982,5 33B1039havnagar. 1

Historical Background
CCHF like symptoms were described initially by
physicians in 12th century from the region
currently known as Tazhikistan.
In 1944-1945 when 200 Soviet military personnel
were infected during war in Crimea.
In 1967 peoples from Congo and Uganda were
infected by similar disease thus the name
Crimean Congo hemorrhagic fever.
In 1967, Chumakov in Moscow first used newborn
white mice for the isolation of CCHF virus. This resulted
in a Drosdov strain which became the prototype strain
for experimental work.
26 August 2014 Dr. Sunil Panjwani, 9825331039 2

Problem statement
52 countries
More than
6,000
cases
Nearly
140
outbreaks

Geographical distribution
• Geographically this tick borne viral infection has
been reported from different countries in
Southeast Europe
Asia
Middle East
Africa

Southeast Europe: outbreaks recorded in Crimea (1944-45), Astrakhan
(1953-63), Rostov (1963-1969), Bulgaria (1953-74, 1975-96, 1997-2003),
Albania (2001), Kosovo (2001), and Turkey (2002-2005 & 2007-2008) .
Asia: outbreaks recorded in China (1965-94, 1994-1995), Kazakhstan
(1948-1968), Tajikistan (1943-1970), Pakistan (1976, 1994, 2010) and
India Ahmedabad (2011) .
Middle East: outbreaks recorded in United Arab Emirates (1979, 1994-
1995), Sharjah (1980), Iraq (1979-1980), Saudi Arabia (1990), Oman
(1995-1996), and Iran (2003) .
Africa: outbreaks recorded in Zaire (1956), Uganda (1958-1977),
Mauritania (1983, 2004), Burkina Faso (1983), South Africa (1981-1986),
Tanzania (1986), Southwest Africa (1986), Kenya (2000), and Sudan
(2008). Dr. Sunil Panjwani, 9825331039
26 August 2014 6

Gujarat Epidemic
(14 cases and 5 deaths)
Amina (30),
Patient- Died
3 Jan 2011 -
Laboratory
confirmed,
epidemiologically
linked
Gagan Sharma (30), doctor -
Died January 13 - Laboratory
confirmed, treated Amina
Asha John (25), Nurse - Died
January 18 - Laboratory
confirmed, treated Amina
Male nurse – Died January
21, Laboratory confirmed,
treated Amina
Hussain Rehman - Alive,
recovered, Lab confirmed,
Amina's husband
Shabbir Ali Umatiya
(25),Intern - Died January
31- Laboratory confirmed
26 August 2014 Dr. Sunil Panjwani, 9825331039
7

• Crimean-Congo haemorrhagic fever (CCHF) is a viral
haemorrhagic fever caused by Nairovirus.
• Primarily an animal disease, sporadic cases and
outbreaks of CCHF affecting humans do occur.
• CCHF outbreaks constitute a threat to public health
because of its
Epidemic potential.
High case fatality.
Potential for nosocomial outbreaks.
Difficulties in treatment and prevention.

• Serious endemic CCHF outbreaks in Europe,
Asia and Africa .
• The presence of human antibodies to CCHF
virus were shown in
Woodcutters
Farmers
Health and animal care workers
 Slaughterhouse workers
People that had tick bites in endemic areas

• Nosocomial outbreaks have been reported in recent
years in Pakistan, Iraq, Dubai, India and South Africa
Year of outbreak Location No. of Cases
2008 Bulgaria 1(1)
2008 Sudan 100(3)
2008 Turkey 688(1)
2009 Iran 2(4)
2009 Kazakhstan 19(3)
2009 Tajikistan 19(3)
2010 pakistan 90(10)
2011 India 14(5)
10

India
• CCHF viral infection had not been reported in
humans from India before 2011, though
previous seroprevalence studies have shown
viral antibodies both in animals and humans.
Shanmugam et al. in 1973 evidence of CCHF
virus antibodies ( Sample from all over India)
643 Human Sample -9 +ve from Kerala and
Pondicherry
655 serum samples from sheep, horse, goat, and
domestic animals - 34 +ve
11

• This virus has veterinary importance in India
and has been demonstrated in ticks, men, and
sheep.
• The recent outbreak in 2011 of CCHF viral
infection in Gujarat is the first notable report
from India.
• The striking feature of this outbreak was high
fatality and rapid spread among treating
medical team.

The Etiological Agent
• The CCHF virus is a member of the Nairovirus
genus under family Bunyaviridae.
• Genus Nairovirus has
Seven serogroups
34 tick-borne species.
• Among these, only three members are known
to cause disease in humans and they are
CCHFV
Nairobi sheep disease virus,
Dugbe virus.

Virion Structure
• Spherical
• 80-120 nm diameter
• Enveloped
• Glycoprotein spikes 8-10 nm in length.
• Helical nucleocapsid
• No matrix protein
• Possess small morphologic surface units with
no order in central holes arrangement.

Structural Proteins
Membrane
glycoproteins
(G1 and G2)
Nucleocapsid
proteins (N)
Polymerase
(L)
 With the availability of nucleotide and amino acid
sequence information, extensive genetic diversity
has been shown in these viruses.

DISSEMINATION
• RESERVOIR: Mammals, including hares, hedgehogs,
rodents, and birds have been implicated as reservoirs
of CCHFV; however, it is believed that they are more
likely to be amplifying hosts rather than true reservoirs
.Ticks of the Hyalomma spp. also act as a reservoir .
• ZOONOSIS: CCHFV can be transmitted to humans via
exposure to infected tissues/secretions during the
slaughtering of infected animals, and via exposure to
small-particle aerosols from infected rodent excreta .
Zoonosis is also possible indirectly via infected tick
bites .
• VECTORS: The Hyalomma species of tick (in gujarati it’s
known as “itaddi”) are the most important vector for
CCHFV. Other tick species vectors of CCHFV include
Rhipicephalus, Ornithodoros, Boophilus,
Dermatocentor, and Ixodes species

• These vectors have both trans-ovarial and
trans-stadial transmission of virus.
• Immature ticks (nymphs) generally inhabit
smaller animals, while mature ticks transmit
the infection to large vertebrates such as
livestock.

Figure 1
Modes of transmission of CCHF virus, (a) Tick cycle, 1- adult, 2- eggs, 3- larvae, 4-
nymph; (i) Trans-ovarian, (ii) Trans-stadial; (b) Tick- Small vertebrate cycle; (c) Tick-
Large vertebrate/bird/human cycle; (d) Human- Human cycle (community/
nosocomial)

At-risk population
• Animal handlers, livestock workers, and slaughter
houses in endemic areas are at risk of CCHF.
• Healthcare workers in endemic areas are at risk of
infection through unprotected contact with infectious
blood and body fluids.
• Individuals and international travelers with contact to
livestock in endemic regions may also be exposed.
• Age – all ages.
• Sex – 3 times more in males than females.
• Immunity – Life time immunity for that genome.

Environmental factors
• Highest incidence of the disease has been
reported between March to May and again
between August to October .
• This incidence increase was mainly attributed in
climatic conditions changes that facilitated tick
reproduction.
• Global warming may change the epidemiological
behaviour of CCHF and in particular it may create
a great problem in prevalent areas by altering the
ticks’ growth patterns, as well as in areas free of
CCHF, by redirecting the migration routes of birds
-which host the affected ticks- to areas newly
warmed by earth’s altered temperature patterns.

Mode of transmission
• Bite of an infective adult tick, particularly
Hyalomma marginatum or Hyalomma
anatolicum.
• Skin lesions when crushing an infected tick.
• Nosocomial outbreaks due to exposure to
infected blood and secretions.
• Slaughtering of infected animals via small-particle
aerosol from infected rodent excreta.
• From contaminated needle sticks or infected
fomites.

Incubation period
• This depends on the route of exposure to
virulence and viral dose.
• The incubation period after tick bite is usually
1 to 3 days, with a maximum of 9 days.
• The incubation period following contact with
infected blood or tissues is usually 5 to 6 days,
with a documented maximum of 13 days.

Case definitions
• Suspected Case
Patient with sudden onset of illness with
high-grade fever over 38.5°C for more than
72 hrs and less than 10 days, especially in
CCHF endemic area and among those in
contact with sheep or other livestock
(shepherds, butchers, and animal handlers).
Fever is usually associated with headache and
muscle pains and does not respond to
antibiotic or antimalarial treatment.

• Probable case
– Suspected case with acute history of febrile illness
10 days or less, AND
Thrombocytopenia < 50,000/cmm AND any two
of the following haemorrhagic manifestations :
Petechiae, Purpuric rash, Epistaxis, Haematemesis,
Haemoptysis, Blood in stools, Ecchymosis, Gum
bleeding, or any other haemorrhagic symptom in
absence of any known precipitating factor for
haemorrhagic manifestations.

• Confirmed case
– Probable case with positive diagnosis of
CCHF in blood sample, performed in
specially equipped high bio-safety level
laboratories, shows,
– Confirmation of presence of IgG or IgM
antibodies in serum by ELISA
– Detection of viral nucleic acid in specimen
by PCR
– Isolation of virus

Definition, monitoring of contacts and Laboratory
testing for contacts of CCHF cases.
Definition of
“contact”
Contacts include: family, neighborhood and
health care facility contact
Monitoring
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 blood
for CCHF
 Appropriate laboratory test is recommended
in persons meeting the case definition.

Patients are divided into 3 categories:
Category-A
Those that have relatively mild disease
Fever < 38.50C,
No systemic bleeding,
Alanine Transaminase (SGPT) levels < 150 IU,
Platelet count > 50,000).
These patients improve spontaneously in about day 10 of
illness. Patient can be managed with supporting therapy and
regular monitoring for worsening of symptoms.
These patients do not require Ribavirin.

• Category-B
Those who are in the first 5 days of illness and are severely ill with
High grade fever (> 38.50C),
Local and systemic bleeding manifestations
Alanine Transaminase (SGPT) levels of 150 IU or more,
Aspartate aminotransferase (SGOT) of 200 IU or more,
Platelets (< 50,000) or D
Activated Partial Thromboplastin Time (APTT) of >60 seconds
Even if the patients still look comparatively well at this stage
these clinical path values are markers of poor prognosis if
recorded during the first 5 days of illness and persons in this
group should be treated as soon as possible with ribavirin.
Those who are recognized and treated early enough respond
remarkably well to ribavirin(11).

• Category-C
• Patients first seen/recognized as CCHF after day 5
and are in comatose/terminal state with DIC and
multi organ failure.
• Treatment with ribavirin is indicated but the
prognosis is very poor.
• Category B & C patients, even if they
subsequently test negative, should receive the
full course of ribavirin.

Clinical Features
• Course of this disease follows four distinct
phases in humans
–Incubation phase
–Pre-hemorrhagic phase
–Hemorrhagic phase
–Convalescence phase

Incubation phase
• The length of the incubation period for the
illness appears to depend on the mode of
acquisition of the virus. Following infection via
tick bite, the incubation period is usually 1 to
3 days, following contact with infected blood
or tissues is usually 5 to 6 days.

Pre-hemorrhagic phase
Pre-hemorrhagic phase is characterized by a
Sudden onset of fever as high as 39-41°C, chills
Severe headache, myalgia, rash
Arthralgia, dizziness, photophobia.
Back and abdominal pain.
Additional symptoms such as
Nausea, vomiting, diarrhea
Loss of appetite.
Neuropsychiatric manifestations like violent
behavior, psychosis, change in mood and
confusion etc.
Hypotension , tachycardia

Hemorrhagic phase
• In severe cases after 3-6 days of the onset of symptoms
hemorrhagic manifestations occur. The spectrum of
hemorrhages varies from petechiae & ecchymoses over
skin and mucus membranes to serious intracraneal bleed.
• Red eyes, flushing of face,
• Throat congestion and petechiae over palate.
• Epistaxis or dark coffee-colored vomitus due to
hematemesis or tar-colored stools i.e. malena or
hematuria.
• Bleeding from other sites like vagina, gum bleeds and
intracerebral bleeds.
• Jaundice, hypovolumic shock, disseminated intravascular
coagulation (DIC),
• Prerenal failure and Lung failure.
• Multiorgan dysfunction syndrome (MODS)

Convalescence phase
Patients who survive this phase, the
convalescence period begins about 15–20 days
after onset of illness. It is generally characterized
by
• Prolonged and pronounced generalized weakness
• Sometimes complete loss of hair.
• Sequelae include polyneuritis, headache,
dizziness, poor appetite, poor vision, loss of
hearing, and loss of memory.
• These are rarely permanent, but may persist for a
year or more.

Symptoms -First 5 days
Symptoms %
• Malaise and fatigue 94-100
• Myalgia and arthralgia 62-100
• Fever 75-100
• Nausea and vomiting 73-90
• Headache 76-85
• Diarrhea 30-38
• Cough 29-30
• Abdominal pain 28
• Confusion 8-14

Symptoms -After 5 days
Symptoms %
• Epistaxis 17-52
• Hematemesis 7-34
• Melena 1-14
• Hemoptysis 9
• Hematuria 8-19
Bleeding from
Other sites %
• Vagina 11
• Subcutanous 30
• Gingiva 8
• Ear 1
• Intaabdominal 2
• Intracranial 1
• Multiple sites 3-25

Signs of CCHF
Signs
• Fever
• Bleeding
• Hepatomegaly
• Lymhadenopathy
• Maculopapular rash
• Pethechia and ecchymosis
• Lung involvement
• Splenomegaly
• Peritoneal irritation
• Conjunctivitis
• Cardiac involvement
• Neck stiffness
• Jaundice
%
43-85
29-48
30-43
13-40
29-57
30-46
4-28
14-23
12-21
11-50
1-11
11
1-12

Diagnosis
• There are no rapid diagnostic tests.
• ELISA-for IgG and IgM from 6th day of illness.
IgM - upto four months
IgG - upto five years.
• The virus may be isolated from blood or tissue
specimens in the first five days of illness, and
grown in cell culture.
• PCR and RT PCR-for detecting the viral
genome

Laboratory diagnostic of CCHF

Laboratory Findings
Increased %
• Lactate dehydrogenase(LDH) 98--100
• Aspartate aminotransferase(AST) 91--100
• Alanine aminotransferase(ALT) 73--100
• Creatine phosphokinase(CPK) 24--90
• Blood urea nitrogen(BUN) 21
• Creatinine levels 91
• Thrombocytopenia 99
• Leukopenia 98-100
• Anemia 75-90
• Proteinuria 11-53
• Hematuria 42
Prolonged %
• Prothrombin time (PT) 21
• Active prothrombin time ( aPTT) 24-66
26 August 2014 Dr. Sunil Panjwani, 982533aPTT1039 49

Pathogenesis
• Capillary fragility suggesting infection of the
endothelium.
• Haemostatic failure by stimulating platelet
aggregation and degranulation, with
consequent activation of the intrinsic
coagulation cascade.
• Reactive hemophagocytosis.
• Proinflammatory cytokines like IL-1, IL-6, and
TNF-alpha also contribute in pathogenesis and
mortality

Differential Diagnosis
• There are a number of tropical infections which
presents similar clinical features and hence they should
be suspected and ruled out while making a diagnosis of
CCHF. The differentials include
– Dengue Hemorrhagic Fever
– Falciparum malaria
– Leptospirosis
– Typhoid Fever
– Septicemic Plague
– Rickettsial Infections
– Meningococcemia
– Viral Hepatitis
– Other viral hemorrhagic fevers.

Treatment
• The mainstay of treatment in CCHF is
supportive in nature
Maintenance of fluid and electrolyte balance.
Maintenance of circulatory volume, and blood
pressure.
Platelet transfusion, PCV transfusion.
Management of DIC, sepsis, shock and MODS
• Possible benefits with gammaglobulin
obtained from immunization of horses.

• Antivirus drug Ribavirin, the dosage
recommended by the WHO within 24 hours of
hospital admission for better results are
2 gm loading dose
 4 gm/day in 4 divided doses for 4 days.

Dosage in Adults
IV Oral
D1 17 mg/kg(max 1000 mg per dose) 2000 mg
Loading dose
d1-4 17 mg/kg(max 1000 mg per dose) q 6h 1000 mg q 6h
d5-10 8 mg/kg(max 500 mg per dose) q 8h 500 mg q 6h

Dosage in Children
IV Oral
D1 Loading dose 17 mg/kg 30 mg/kg
d1-4 17 mg/kg q 6h 15 mg/kg q 6h
d5-10 8 mg/kg q 8h 7 mg/kg q 6h

• Currently in Indian markets Ribavirin available
in oral form with tablet strength of 200 mgs, if
it is considered for use the approximate cost
of 10 day therapy with this drug would
currently be around Rs 6000/- for each patient
with an average weight of 50 Kg.
• Ribavirin is contraindicated in pregnancy and
in children.

Treatment Protocol
• If the patient meets the case definition for
probable & confirm CCHF, ribavirin treatment
protocol needs to be initiated immediately.
• Pregnancy should be absolutely prevented
(whether female or male partner) within six
months of completing a course of ribavirin.
Treatment Protocol for CCHF disease
High-dose oral Ribavirin therapy :
 2 gm loading dose
 4 gm/day in 4 divided doses (6 hourly) for 4 days.
57

New treatment strategies
• Interferons and interferon-stimulated antiviral
proteins:
– MxA (interferon-induced GTPases)
• Antibodies to CCHF:
– Gammaglobulin obtained from immunisation
of horses
– Development of monoclonal antibodies would
allow better control Appropriate treatment of
secondary infections should be instituted.

Postexposure Prophylaxis
Mucous membrane contact (kissing or sexual contact
with a patient)
Percutaneous injury in contact with the patients’
secretions, excretions, or blood.
Exposed to hemorrhagic fever viruses (including
CCHFV) in a bioterroristic attack
Living or in cotact with the patients
Who process laboratory specimens.
59

Prophylaxis Protocol
Indirect contact with case body fluids should be monitored for
14 days from the date of last contact with the patient or other
source of infection by taking the temperature twice daily.
OR
If the patient develops a temperature of 38.5° C or greater,
headache and muscle pains, he/she would be considered a
probable case and should be admitted to hospital and started
on ribavirin treatment.
Treatment Protocol for CCHF disease
High-dose oral Ribavirin therapy :
 2 gm loading dose
 4 gm/day in 4 divided doses (6 hourly) for 4 days.
60

Prognosis
Overall case-fatality rate
Case-fatality rate with
Hemorrhagic manifestations,
confusion, and laboratory
evidence of marked
elevation of AST, ALT, GGT,
CPK, LDH, frank DIC,
thrombocytopenia.
5% to 40%
15% to 70%
61

Prevention of transmission
Reducing the risk of infection in people
• Awareness and educating to reduce the exposure
to the virus.
• How to safely remove ticks
Public health educational messages should focus
on the following:
• Reduce the risk of animal-to-human transmission
– Eliminating or at least controlling tick infestations on
animals or in stables/barns.
– Quarantine for animals before they enter
slaughterhouses or routine treatment of ruminants
with pesticides 2 weeks prior to slaughter.
– Using masks, gloves and gowns when slaughtering and
butchering animals.

• Reduce the risk of tick-to-human transmission
– Avoid tick bites
– Remove ticks safely from the skin.
• Close physical contact with CCHF patients
should be avoided. Use PPE during care of ill
patients at home.
• Regular hand-washing after visiting sick
relatives in hospital, as well as while taking
care of ill patients at home should be carried
out.

Prevention and Control in Public
Educate public about the mode of transmission.
Tick control with acaricide(DDT,BHC,Malathion)
Avoid tick-infested areas from spring to fall to
minimize exposure
Wear light clothing that covers legs and arms,
tuck pants into socks, regularly examine clothing
and skin for ticks
Apply tick repellent such as diethyltoluamide
(Deet, Autan) to the skin or permethrin (a
repellent and contact acaricide) to pant legs and
sleeves.

 Consumption of unpasteurized milk and uncooked
meat should be avoided.
 Butchers should wear gloves and other protective
clothing to prevent skin contact with infected
tissues or blood.
 In case of death of CCHF patient, family should be
informed to follow safe burial practices.

Safe Burial practices
• Thick and long rubber gloves or double pair of
surgical gloves should be used for washing the
body for burial.
• The dead body should be sprayed with 1:10 liquid
bleach solution and then placed in a plastic bag
which should be sealed with adhesive tape.
• It should then be wrapped in the winding sheet
(kafan) for burial / burn .
• Disinfect the transport vehicle by spraying 1:10
liquid bleach solution on any surfaces touching
the body and burn all clothing of the deceased.
66

Prevention and Control: Hospitals and
Health Facilities
• Healthcare workers who have had contact with
tissue or blood from patients should be followed
up with daily temperature and symptom
monitoring for at least 14 days .
• Doctors and healthcare workers in endemic areas
where the virus has emerged should be sensitized
to the occurrence and educated to diagnose,
report, and treat the cases.
• Community education initiatives should be
instituted in the event of an observed outbreak.

• Hospitals should maintain stock of Ribavirin.
• CCHFV can be inactivated by
 1% hypochlorite ,2% glutaraldehyde, 70% alcohol
 Heating at 56°C for 30 min, 60°C for 15 minutes.
 UV light (1,200 to 3,000 μW/cm2),
 Low pH (less than 6).

SURVIVAL OUTSIDE HOST
• The virus is stable under wet conditions for
 7 hours at 37 °C
 11 days at 20 °C
 15 days at 4°C.
• Under dry conditions, the virus is stable for
 90 minutes to 24 hours.

Bio-safety measures
1) The patient should be treated in a separate room under
strict barrier nursing.
2) Only designated medical / para-medical staff and
attendants should attend the patient. Non-essential staff
and attendants should not be allowed to enter the room.
3) All secretions of the patient and hospital clothing in use of
the patient should be treated as infectious and should be
autoclaved before incinerating.
4) All medical and para-medical staff and attendants should
wear disposable gloves, disposable masks and gowns
(gowns should be autoclaved before sending to the
laundry or incineration). Use of disposable items should be
26 Auguestn 20s14ured by supervisDor. rS.unil Panjwani, 9825331039 70

Bio-safety measures contd…
5) Every effort should be made to avoid spills, pricks,
injury and accidents during the management of
patients. Needles should not be re-capped but
discarded in proper safety disposal box.
6) All used material e.g. syringes, gloves, canulla,
tubing etc, should be collected in autoclave-able
bag and autoclaved before incinerating.
7) All instruments should be de-contaminated and
autoclaved before re-use.
8) All surfaces should be decontaminated with liquid
bleach.
71

Bio-safety measures contd…
9) The samples for laboratory testing should be properly
collected, labelled, sealed, and decontaminated from
outside with liquid bleach and packed in triple container
packing.
10) The designated laboratory should be informed about
the sample and it should be transported to the
designated laboratory with great caution, ensuring there
would be no breakage or spills.
11) After the patient is discharged, room surfaces should
be wiped down with liquid bleach to kill the virus and
the room should be fumigated.
72

Outbreak response
• Reduce the disease burden through
– Integrate standard operating procedures for outbreak
response that include vector (ticks), animal and human
health components.
– Design and perform "Train-the-Trainer" courses for CCHF
outbreak response with regional teams.
– Develop standard case management training for CCHF.
– Develop a manual for healthcare providers that would
include clinical descriptions, treatment options and
recommended laboratory tests.
– Improve emergency preparedness and response.
– Implement/Strengthen national tick-control programmes.
– Health education

Check list for Hospitals treating suspected case of CCHF
No. Particulars Action
1 Suspected for CCHF? Yes/ No
2 Patient Isolated? Yes/ No
Exposure to cattle or same symptomatic patient in last week?
History of visit abroad or across state within last week?
3 Are the patients relatives screened for similar symptoms? Yes/ No
4 Are the patient's attendant counselled temp monitoring regularly? Yes/ No
5 Is the local health authority informed? Yes/ No
6 Use PPE by treating staff Yes/ No
7 Blood Sample taken? Yes/ No
8 Blood Sample sent to NIV using triple layer container and
in reverse cold Chain?? Yes/ No
9 Is the duly filled CRF in standard format along with sample? Yes/ No
10 Whether following Blood Investigation conducted?
SGPT, Yes/ No
SGOT, Yes/ No
Platelet count Yes/ No
APTT Yes/ No

Check list for Hospitals treating suspected case of CCHF
( Cont… )
11 Whether the daily laboratory findings are being plotted? Yes/ No
12 Categorize the patient according to annexure I Yes/ No
13 If category A, supportive treatment given? Yes/ No
14 If category B, Ribavirin given? Yes/ No
15 Is patient recovering or clinically worsening? Yes/ No
16 Critical care given? Yes/ No
17 If category C, Ribavirin given? Yes/ No
18 Critical care given? Yes/ No
19 Does patient show signs of DIC? Yes/ No
20 Multi organ failure? Yes/ No
21 Is patient Intubated? Yes/ No
22 Is bio medical waste disposal guidelines adhered strictly? Yes/ No
23 Patient's outcome
Recovered - Follow up & Precautions for future advised? Yes/ No

Check list for Field Health staff in suspected case of CCHF
No. Particulars Action
1 Suspected for CCHF? Yes/ No
2 Referred to tertiary care hospital? Yes/ No
3 State and District authorities are informed? Yes/ No
4 Other concerned departments are informed? Yes/ No
5 Surveillance started? Yes/ No
6 Is the surveillance team is duly protected by PPE? Yes/ No
7 Close Contact identified? Yes/ No
8 Contact list prepared? Yes/ No
9 Contact Blood samples are taken? Yes/ No
10 Daily Temperature Monitoring of close contact ensured? Yes/ No
11 Tick Control measures initiated? Yes/ No
12 Tick samples taken and sent? Yes/ No
13 Animal sera samples taken? Yes/ No
14 Health Education given? Yes/ No
15 Risk Analysis done? Yes/ No
16 Private consultation for same symptomatic patients? Yes/ No
17 Inter Departmental Co-ordination ensured? Yes/ No

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