The WHO said nosebleed fever or CCHF is a viral tick-borne disease transmitted to humans through bites from infected ticks and through direct contact with blood or tissues of infected people and livestock.
Iraq has witnessed an outbreak of nosebleed or Crimean Congo hemorrhagic fever (CCHF) and so far this year 212 cases have been detected and 27 people have died. India has now reported two cases from Gujarat and one death.
According to the World Health Organization (WHO), nosebleeds are endemic in Africa, the Balkans, the Middle East and Asia.
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It is estimated that 3 billion people are at risk with 10,000 to 15,000 infections per year and an estimated 500 deaths per year.
The first CCHF case in India was reported from Gujarat in 2011. According to WHO’s geographical distribution of nosebleeds, India reports 5 to 49 infections annually.
What is CHF?
Crimean Congo hemorrhagic fever is a viral hemorrhagic fever usually transmitted by ticks. It can also be contracted through contact with viremic animal tissues (animal tissue where the virus has entered the bloodstream) during and immediately after animals are slaughtered, the WHO said.
CCHF outbreaks pose a threat to public health services as the virus can lead to epidemics, has a high mortality rate (10-40%), potentially leading to outbreaks in hospitals and health facilities, and is difficult to prevent and treat, it added to.
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“The hosts of the CCHF virus include a wide range of wild and domestic animals such as cattle, sheep and goats. Many birds are resistant to infection, but ostriches are susceptible and can show a high prevalence of infection in endemic areas, where they have been the cause of human cases. For example, an earlier outbreak took place in an ostrich slaughterhouse in South Africa. There is no apparent disease in these animals.
“Animals become infected through the bite of infected ticks and the virus remains in their bloodstream for about a week after infection, allowing the tick-animal-tick cycle to continue when another tick bites. Although a number of tick genera are able to become infected with the CCHF virus, the main vector is ticks of the genus Hyalomma,” explains the WHO.
The disease was first described in Crimea in 1944 and was given the name Crimean hemorrhagic fever. In 1969 it was recognized that the pathogen causing hemorrhagic fever in Crimea was the same as that responsible for a disease identified in 1956 in Congo. Linking the two place names resulted in the current name for the disease and the virus.
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Primary Human Infections
The WHO said CCHF is a viral tick-borne disease that is transmitted to humans through bites from infected ticks and through direct contact with blood or tissues of infected people and livestock. About 80 to 90% of people become infected through a tick bite or direct contact with blood from infected ticks; direct contact with blood/tissues from infected wild animals and livestock. Secondary human-to-human transmission occurs through direct contact with the blood, secretions, organs, or other bodily fluids of infected individuals. High transmission risk when providing direct patient care or handling dead bodies (funerals).
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The WHO said studies have shown that sheep and cattle farms are regularly infested with tick species, mainly Hyalomma species, the main vector of CCHF.
Sizes of sign
Ticks live in the ground vegetation and move mainly by climbing on plants and walking on the ground. They cling to a passing animal or human host by means of hooks on their legs. The size of the sign can vary from 0.5 to 15 mm, depending on the type of sign.
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The most common symptoms are sudden onset fever, chills, shivering, muscle aches, headache, nausea and vomiting, abdominal pain, arthralgia. After a few days – bleeding from mucous membranes, hematomas, ecchymosis, melena, hematuria, nosebleed, vaginal bleeding, bradycardia, thrombocytopenia, leukopenia, according to the WHO.
The length of the incubation period depends on the mode of virus acquisition. After infection by a tick bite, the incubation period is usually one to three days, with a maximum of nine days. The incubation period after contact with infected blood or tissue is usually five to six days, with a documented maximum of 13 days, according to the WHO.
Other clinical signs include tachycardia (rapid heart rate), lymphadenopathy (enlarged lymph nodes), and petechial rash (rash caused by bleeding into the skin) on internal mucosal surfaces, such as in the mouth and throat, and on the skin. The petechiae can give way to larger rashes called ecchymoses and other hemorrhagic manifestations. There is usually evidence of hepatitis and critically ill patients may experience rapid renal deterioration, sudden liver failure, or lung failure after the fifth day of illness.
The death rate from CCHF, according to the WHO, is about 30%, with death occurring in the second week of illness. In patients who recover, improvement generally begins on the ninth or tenth day after disease onset.
General supportive care in the management of symptoms is the main approach to treating CCHF in humans and the antiviral drug ribavirin has been used to treat CCHF infections with apparent benefit. According to the WHO, both oral and intravenous formulations appear to be effective.
No vaccines available
The WHO said there are no widely available vaccines for human or animal use. If there is no vaccine, the only way to reduce infection in humans is to raise awareness about the risk factors and educate people about the measures they can take to reduce exposure to the virus.
Reducing the risk of infection in humans
To reduce the risk of transmitting ticks to humans, the WHO recommends the following:
Avoid tick-infested areas; wear protective clothing (long sleeves, long pants); wear light-colored clothing to easily detect ticks on the clothing; use approved acaricides (chemicals intended to kill ticks) on clothing; use approved repellent on skin and clothing; regularly examine clothing and skin for ticks; if found, safely delete them; trying to eliminate or control tick infestations on animals or in stables and barns; and avoid areas where ticks are abundant and seasons when they are most active.
To reduce the risk of animal to human transmission – wear gloves and other protective clothing when handling animals or their tissues in endemic areas, especially during slaughter, slaughter and culling procedures in slaughterhouses or at home; quarantine animals before entering the slaughterhouse or routinely treat animals with pesticides two weeks before slaughter.
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To reduce the risk of human-to-human transmission in the community – avoid close physical contact with CCHF infected people; wear gloves and protective equipment when caring for sick people; wash hands regularly after caring for or visiting sick people.
dr. Samiran Panda, additional director general of the Indian Council of Medical Research (ICMR), told The Indian Express that the government was fully prepared to deal with any possible outbreak of CCHF. “As for the cases from Iraq, severe bleeding, both internal and external, especially from the nose, was observed in two-fifths of the deceased. These are typical symptoms of CCHF cases, regardless of geographic region,” said Dr. Panda.
“Since 2011, the laboratory screening of CCHF for humans, animals and ticks has been ongoing. ICMR’s state-of-the-art containment BSL-4 facility in Pune in 2012 made it possible to rapidly develop native serological tests for the diagnosis of IgM and IgG for humans and IgG for livestock. These indigenous technologies not only helped in the timely diagnosis of suspected CCHF cases, but also in the monitoring of CCHF in humans, livestock and ticks in the country,” senior ICMR scientists told the paper.