International Journal of Infectious Diseases
Volume 13, Issue 3 , Pages e105-e107, May 2009

A case of nosocomial transmission of Crimean–Congo hemorrhagic fever from patient to patient

Dıskapı Yıldırım Beyazıt Training Hospital, Ankara, Turkey

Received 15 July 2008; received in revised form 29 July 2008; accepted 6 August 2008. published online 24 October 2008.

Corresponding Editor: Jane N. Zuckerman

Article Outline

Summary 

Crimean–Congo hemorrhagic fever (CCHF) is an acute, tick-borne viral disease, with the potential for human to human transmission. Infection often has severe hemorrhagic manifestations and considerable mortality. Healthcare workers (HCWs) caring for patients with CCHF constitute a major risk group for infection. Although nosocomial transmission from patients to HCWs accounts for a significant proportion of CCHF cases and outbreaks worldwide, transmission of CCHF from patient to patient has not previously been reported. A case of nosocomial transmission of CCHF from patient to patient at a hospital is described.

Keywords: Nosocomial, Transmission, Crimean–Congo

 

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Introduction 

The CCHF virus is a tick-borne virus of the genus Nairovirus within the family Bunyaviridae. These viruses are transmitted by ticks of the Hyalomma genus, particularly by Hyalomma marginatum marginatum. CCHF is an acute viral disease with the potential for human to human transmission that affects almost exclusively humans. Infection often results in severe hemorrhagic manifestations, with a reported mortality rate of 3–30%.1

The disease was first recognized as a clinical entity during an investigation into an outbreak in Crimea in 1944–1945; it was named Crimean hemorrhagic fever. Subsequently, the causative agent was named Congo virus, after the agent isolated from a human case in the Congo, and the name CCHF virus was established.2 Virus isolation and infection have been documented in more than 30 countries in Africa, Central and Southwestern Asia, the Middle East and Southeastern Europe.3 Since 2002, the disease has been diagnosed throughout Turkey, especially Central Anatolia and Black Sea regions.

The high risk of nosocomial outbreaks of CCHF was first recognized in 1976, when a laparotomy was performed on a CCHF patient in Pakistan with abdominal pain, hematemesis and melena. Eleven secondary cases in hospital staff resulted in three deaths, including the death of a surgeon and an operating-theatre attendant. Since then, similar nosocomial outbreaks have been reported in many countries.4 However, nosocomial infection from patient to patient has not been reported. Nosocomial infections usually have a more severe prognosis. A case of nosocomial transmission of CCHF from patient to patient is described.

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Case report 

In 2006, a 38-year-old female living in a rural area of Ankara was admitted to hospital with high fever, dysuria and metrorrhagia. She had been taking drugs for metrorrhagia for three years. Laboratory findings were as follows: platelets 162×109/l, white blood cells 2.7×109/l, hemoglobin 5.3g/dl, hematocrit 19%.

There was abundant pyuria in the patient’s urine. Urinary tract infection caused by Klebsiella spp. was diagnosed and appropriate antibiotic therapy was given. After three days of hospitalization, there was no clinical improvement and pancytopenia increased. We re-evaluated the patient and learned from one of her relatives that, seven days before admission to hospital, she had been bitten by a tick, which she had removed. This patient was diagnosed with CCHF from IgM antibodies detected by ELISA and from viral RNA detected by reverse transcriptase (RT) PCR. The patient was isolated immediately.

A patient who had shared the same room as the index case for five days had been in hospital for 25 days for treatment of a brain abscess; she had never come into contact with a tick and had never been to an endemic region. After contact with the index case for five days in the same room, she developed CCHF, with fever, chills, myalgia, arthralgia, headache, abnormal liver function and hemorrhagic manifestations, as confirmed by ELISA and PCR. IgM antibodies were detected by ELISA at the Refik Saydam Hygiene Center of Ankara, Turkey. A TaqMan-based one-step RT-PCR assay was used to detect CCHF virus RNA.5 The assay was performed using a Perkin–Elmer 7700 Sequence Detection System using a combination of reverse transcriptase (MBI Fermentas, Vilnius, Lithuania) and hot start Taq DNA polymerase (Brion GmBh, Munchen, Germany) enzymes.

This second patient was regarded as having a nosocomial infection. Neither patient was treated with ribavirin. They recovered about two weeks after the onset of symptoms.

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Discussion 

The index case was the first patient in the CCHF outbreak of 2006 in Turkey. On admission, she did not mention any history of tick bites. However, she had a urinary tract infection and myoma of the uterus, which explained her symptoms.

CCHF is usually acquired by tick bite, contact with infected animal blood or nosocomial transmission.6 Before the index case was admitted to hospital, the second patient had been in hospital for one month, including 5 days in the Brain Surgery Clinic and 25 days in our clinic. Then, she shared a room with the index case for five days. Because of the short incubation period (usually 3–5 days) of the infection following a tick bite or contact with blood, it was impossible for her to be infected by any other way than nosocomial transmission.

Hospital HCWs are at serious risk of transmission of CCHF infection when caring for patients with hemorrhages from the nose, mouth, gums, vagina and injection sites.6 CCHF virus has repeatedly caused nosocomial outbreaks with a high mortality rate. Percutaneous exposure presents the highest risk of transmission.6, 7

Nosocomial transmission of CCHF is well known and has been described in outbreaks that have occurred in Dubai, Pakistan, South Africa, Bulgaria and Turkey.7, 8, 9, 10, 11, 12, 13 In an outbreak that occurred in Dubai, five HCWs developed CCHF and two died. One of the five secondary cases was an interpreter. He had only been in the patient’s room and had not come into contact with the patient. The four other secondary cases had close contact with the patient.11

It was reported that, in Pakistan, nosocomial CCHF transmission occurred during a surgical intervention. One anesthetist and two surgeons developed CCHF after operating on an index case with gastrointestinal bleeding.9

In a South African outbreak, seven secondary cases occurred, three of whom had never been in contact with the index case; however, two had been in the patient’s room and one had contact with medical waste. The rest of the secondary cases had contact with the index case and three of them were exposed to needle contact. Finally, one of the secondary cases who had not come into contact with the index case died.14 It can be assumed that the CCHF virus can be transmitted by not only patient contact but also contact with medical waste.7

Almost all of these nosocomial transmissions are from patients to HCWs. There have not been any previously published case reports on patient to patient nosocomial transmission of CCHF. In this report, we describe patient to patient nosocomial transmission of CCHF. We do not know for certain how she became infected by the index case.

Based on experience in Africa, the transmission of viral hemorrhagic fevers has been associated with the reuse of non-sterile needles and syringes, and with the provision of patient care without appropriate barrier precautions to prevent exposure to virus-containing blood and other body fluids (including vomit, urine and stool).15, 16, 17 There has been no reuse of sterile or non-sterile needles and syringes in Turkey for a long time. Because the history of tick bite was not known, strict contact isolation measures, which must be taken for CCHF patients, were not carried out when the two patients were treated in the same room. Therefore, while sharing the same room for five days, the secondary case might have had some kind of contact with the index case’s infected blood or body fluids. Indeed, as she had a urinary infection and metrorrhagia, the index case frequently used the toilet, which was also used by the secondary case. Using the same toilet might have caused transmission of the virus with blood and/or body fluids from patient to patient. In addition, they might have shared personal items with infected body fluids. The other remote possibility is airborne transmission.15, 16, 18 Airborne transmission of CCHF infection was suspected in several cases in Russia, but was not documented.19, 1

Conflict of interest: No conflict of interest to declare.

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References 

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PII: S1201-9712(08)01460-4

doi:10.1016/j.ijid.2008.08.002

International Journal of Infectious Diseases
Volume 13, Issue 3 , Pages e105-e107, May 2009

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