Management and Treatment Congo hemorrhagic fever

1. Management and Treatment Congo hemorrhagic fever Dr. D. Steyn Department of Internal Medicine UOFS

3. Syndromes - Zoonotic viruses • VHFs are zoonotic infections and only occasionally cause illness in man • fever and myalgia • arthritis and rash • encephalitis • haemorrhagic fever

4. Crim-Congo Haemorrhagic Fever • 1944 - Crimean region (Soviet Union) • 1956 - Congo • 1981 - 1st case in RSA (10 - 12 cases/y) • Reservoirs: cattle, sheep, goats, birds (ostriches) and hares • Vector: Hyalomma tick (“bontpootbosluis”) • Humans become infected by contact with ticks or blood (not airborne)

7. Larvae and nymphs feed on small mammals • up to hare size • and ground-frequenting birds • while adults prefer • large animals • Prof. R Swanepoel

8. Humans gain infection from • tick bite • or • from contact of infected fresh blood (or other tissues) • with broken skin • infected blood/tissues coming either from human patients • (nosocomial infections - needle sticks etc) or otheranimals, commonly sheep and cattle • Prof. R Swanepoel

9. Airborne transmission • Airborne transmission involving humans is considered a possibility only in rare instances from persons with advanced stages of disease • (e.g., one patient with Lassa fever who had extensive pulmonary involvement may have transmitted infection by the airborne route)

10. Clinical manifestation • Incubation period: 3-6 days !! • Abrupt onset (Flu-like symptoms) • High fever with chills (400C, +/- 8 days) • Severe headache • Myalgia (back ache) • Arthralgia • Abdominal pain

11. Clinical manifestation • Nausea/vomiting • Sore Throat • Conjunctivitis • Jaundice (hepatomegaly 50%) • Splenomegaly (2-25%) • Photophobia • Flushing of the face • Dry tongue, with a coating of dry blood

13. Complications of CCHF • Diarrhoea, vomiting, dizziness, confusion and abnormal behaviour • Haemorrhagic manifestations • oozing from arterial or venous puncture sites • petechiae, purpura, ecchymosis • mucosal bleeding • epistaxis,hemoptysis • haematemesis/ melena • adrenal bleeding

15. Complications of CCHF • DIC in the most severe cases • Hepatic dysfunction • severe hepatitis and necrosis • Kidney failure • Respiratory failure(ARDS) • Mostly in the severely ill, > 5th day

16. Complications of CCHF • uncontrollable haemorrhage • shock • intercurrent infection • multi-organ failure • nuchal rigidity, excitation, coma • Mortality: +/- 30% (15 to 70%)

17. Laboratory results • leucopenia (WCC < 1000/mm3) • severe thrombocytopenia • hepatic dysfunction • markedly elevated liver enzymes • prolonged PT/PTT • Proteinuria / hematuria • Markers of organ failure

18. Poor prognostic markers • WCC  10 x 109/l • Platelet count  20 x 109/l • AST  200 U/l • ALT  150 U/l • APTT  60 seconds • Fibrinogen  110 mg/dl • Any one of these during the first 5 days are highly predictive of a fatal outcome

19. Diagnosis • Physician awareness • contact with livestock/blood of Pt with CCHF/ bitten by a tick/ crushed tick with bare hands • The longer the delay in making the diagnosis, the greater the cost • specific Ab/ virus detection • (biosafety level 4 lab)

20. Differential diagnosis • Meningococ- septicaemia • Malaria • Typhoid • Gram- septicaemia • Severe Rickettsial Diseases (Tick-bite fever) • Hepatitis (fulminant) • DIC/ anticoagulant therapy • Systemic herpes, VZ, CMV, EBV and haemorrhagic measles • Snake-bite

21. Criteria for Clinical dx of CCHF 1.) History of exposure to infection 2.) Signs and symptoms 3.) Clinical pathology during first 5 days of illness Total: > 12 Points Treat as a case of CCHF R Swanepoel, J H Mynhardt, Harvey - 1987

22. 1.) History of exposure Incubation period: < 1w / >1w • Bitten or crushed tick 3 2 • Direct contact with blood/ tissues of livestock 3 2 • Direct contact with blood/ secretions from CCHF Pt 3 2 • Resided or visited rural environment 2 1

23. 2.) Signs and Symptoms • Sudden onset 1 • Fever > 38o C 1 • Severe headache 1 • Myalgia 1 • Nausea +/- Vomiting 1 • Bleeding tendency 3

24. 3.) Clinical pathology (1st 5 days) • WCC < 3 or > 9 1 • Platelets < 150 1 • Platelets < 100 2 • > 50%  WCC/ Pl within 3 days 1 • Abnormal PI 1 • Abnormal PTT 1 • AST > 100 1 • ALT > 100 1

25. Management of a suspected case of VHF: • Universal precautions are generally sufficient during the pre-hospital evaluation and transport • Pts are less likely to vomiting, diarrhoea or haemorrhage • respiratory symptoms (cough or rhinitis) • face shields or surgical masks and eye protection

26. Hospitalization • A negative pressure room is not required during the early stages of illness • barrier precautions • cough, vomiting, diarrhoea, or haemorrhage • additional precautions are indicated to prevent possible exposure to airborne particles • Notification • Observation of Contact Persons (2-3 w)

27. Transfer • Contact your referral hospital • Ideally patients should be managed at the hospital where they are first admitted • they do not tolerate the stress of transfer well, and evacuation increases the potential of secondary transmission • If indicated transfer before bleeding start • Mmeticulous infection practice • Sedation

29. Treatment • Treatment of CCHF is mainly supportive • fluid and electrolyte balance • intensive care / ventilation • Support of specific organ failure • Intensive supportive: sometimes for prolonged periods • Management of severe bleeding • Multiple platelet transfusions • Fresh frozen plasma

30. Treatment • Secondary infections should be treated aggressively with broad-spectrum antibiotics • Convalescent immune serum (first 3 days) • Ribavirin • Convalescence is often slow • Discharge of Patient (+/- after 3 weeks) • Observation of contact persons (2-3 weeks)

31. Notification