Infection prevention and control practice for Crimean-Congo hemorrhagic fever-A multi-center cross-sectional survey in Eurasia

Background

Crimean Congo Hemorrhagic Fever (CCHF) is a life threatening acute viral infection that presents significant risk of nosocomial transmission to healthcare workers.

Aim

Evaluation of CCHF infection prevention and control (IP&C) practices in healthcare facilities that routinely manage CCHF cases in Eurasia.

Methods

A cross-sectional CCHF IP&C survey was designed and distributed to CCHF centers in 10 endemic Eurasian countries in 2016.

Results

Twenty-three responses were received from centers in Turkey, Pakistan, Russia, Georgia, Kosovo, Bulgaria, Oman, Iran, India and Kazakhstan. All units had dedicated isolation rooms for CCHF, with cohorting of confirmed cases in 15/23 centers and cohorting of suspect and confirmed cases in 9/23 centers. There was adequate personal protective equipment (PPE) in 22/23 facilities, with 21/23 facilities reporting routine use of PPE for CCHF patients. Adequate staffing levels to provide care reported in 14/23 locations. All centers reported having a high risk CCHFV nosocomial exposure in last five years, with 5 centers reporting more than 5 exposures. Education was provided annually in most centers (13/23), with additional training requested in PPE use (11/23), PPE donning/doffing (12/23), environmental disinfection (12/23) and waste management (14/23).

Conclusions

Staff and patient safety must be improved and healthcare associated CCHF exposure and transmission eliminated. Improvements are recommended in isolation capacity in healthcare facilities, use of PPE and maintenance of adequate staffing levels. We recommend further audit of IP&C practice at individual units in endemic areas, as part of national quality assurance programs.

Crimean-Congo Hemorrhagic Fever Knowledge, Attitudes, Practices, Risk Factors, and Seroprevalence in Rural Georgian Villages with Known Transmission in 2014

In 2014 the highest annual case count of Crimean-Congo hemorrhagic fever (CCHF) was detected in Georgia since surveillance began in 2009. CCHF is a high-fatality hemorrhagic syndrome transmitted by infected ticks and animal blood. In response to this immediate public health threat, we assessed CCHF risk factors, seroprevalence, and CCHF-related knowledge, attitudes, and practices in the 12 rural villages reporting a 2014 CCHF case, to inform CCHF prevention and control measures. Households were randomly selected for interviewing and serum sample collection. Data were weighted by non-response and gender; percentages reflect weighting. Among 618 respondents, median age was 54.8 years (IQR: 26.5, range: 18.6–101.4); 215 (48.8%) were male. Most (91.5%) participants reported ≥1 CCHF high-risk activity. Of 389 participants with tick exposure, 286 (46.7%) participants handled ticks bare-handed; 65/216 (29.7%) knew the risk. Of 605 respondents, 355 (57.9%) reported animal blood exposure; 32/281 (12.7%) knew the risk. Of 612 responding, 184 (28.8%) knew protective measures against CCHF and tick exposures, but only 54.3% employed the measures. Of 435 serum samples collected, 12 were anti-CCHF IgG positive, indicating a weighted 3.0% seroprevalence. Most (66.7%) seropositive subjects reported tick exposure. In these villages, CCHF risk factors are prevalent, while CCHF-related knowledge and preventive practices are limited; these findings are critical to informing public health interventions to effectively control and prevent ongoing CCHF transmission. Additionally, CCHF seroprevalence is higher than previously detected (0.03%), highlighting the importance of this disease in the South Caucuses and in supporting ongoing regional investigations.

Hospital-Based Surveillance for Infectious Etiologies Among Patients with Acute Febrile Illness in Georgia, 2008-2011

Information on the infectious causes of undifferentiated acute febrile illness (AFI) in Georgia is essential for effective treatment and prevention. In May 2008, a hospital-based AFI surveillance was initiated at six hospitals in Georgia. Patients aged ≥ 4 years with fever ≥ 38°C for ≥ 48 hours were eligible for surveillance. Blood culture and serologic testing were conducted for Leptospira spp., Brucella spp., West Nile virus (WNV), Crimean-Congo hemorrhagic fever virus, Coxiella burnetii, tick-borne encephalitis virus (TBEV), hantavirus, Salmonella enterica serovar Typhi (S. Typhi), and Rickettsia typhi. Of 537 subjects enrolled, 70% were outpatients, 54% were males, and the mean age was 37 years. Patients reported having fatigue (89%), rigors (87%), sweating (83%), pain in joints (49%), and sleep disturbances (42%). Thirty-nine (7%) patients were seropositive for R. typhi, 37 (7%) for Brucella spp., 36 (7%) for TBEV, 12 (2%) for Leptospira spp., 10 (2%) for C. burnetii, and three (0.6%) for S. Typhi. None of the febrile patients tested positive for WNV antibodies. Of the patients, 73% were negative for all pathogens. Our results indicate that most of the targeted pathogens are present in Georgia, and highlight the importance of enhancing laboratory capacity for these infectious diseases.

[ETHIOLOGY OF LEPTOSPIROSIS IN GEORGIA]

Investigation of leptospirosis was initiated in 1950s, when the first cases in humans were detected in Gudauta rayon. Serology test confirmed the diagnose. High level of antibodies to serogroup Pomona was revealed in all cases. Later on the infection encountered as sporadic cases, the exception was 1986, when a large outbreak was reported in Sukhumi. At present leptospirosis is widely spread in the country, especially in Ajara region, where indicators of morbidity recently reached 11.4 per 100 thousand population. It is likely that warm humid climate creates exceptionally favorite conditions for spreading of Leptospira. In order to determine the true magnitude of the infection in the country a seroprevalence study was carried out in 50-60-ies of the past century in humans, agricultural animals and rodents. It was found that serotgroups Pomona, Icteroheamorrhagiae and Grippothypos prevailed in humans, Serogroup L. Pomona - dominated in animals, while in rodents the dominated serotgrouo was L. Icteroheamorrhagiae. Similar study, conducted by us in 1990-2005 showed that L.Pomona and L. Icteroheamorrhagiae prevailed in humans and rodents while L. Icteroheamorrhagiae was the only serogroup isolated in gray rats, trapped in Tbilisi. Infectivity of rodants composed 70%. Currently lesptosirosis is caused by a new serogroups of Leptospira - L. Sejroe, namely by serotypes Wolfii and Hardjo, L. Australis (serotype Bratislava) and L. Autumnalis along with the previously occurring serogroups L. Icteroheamorrhagiae, L. Bataviae, L. Hebdomadis. In our opinion the recent increase in leptospirosis in the country is attributable to the improvements in diagnostics of the infection as well as to the emergence of new serogroups of Leptospira, which in turn is a result of intensive migration processes in the country.

Notes from the field: Increase in reported Crimean-Congo hemorrhagic fever cases--country of Georgia, 2014

During January-September 2014, Georgia's National Centers for Disease Control and Public Health (NCDC) detected 22 cases of Crimean-Congo hemorrhagic fever (CCHF) in the country. CCHF is caused by infection with a tickborne virus of the Bunyaviridae family. Transmission occurs from the bite of an infected tick or from crushing an infected tick with bare skin. Secondary transmission can result from contact with blood or tissues of infected animals and humans. CCHF initially manifests as a nonspecific febrile illness that progresses to a hemorrhagic phase, marked by rapidly developing symptoms leading to multiorgan failure, shock, and death in severe cases. The clinical severity, transmissibility, and infectiousness of CCHF are responsible for its categorization as a viral hemorrhagic fever high-priority bioterrorism agent.

[Leptospirosis in Georgia]

The aim of the article was to study epidemiological patterns of leptospirosis in Georgia from 2001 to 2011. The investigation revealed that formal registration of the infection began in 1950s. Single cases were reported annually in the country with the exception of 1986, when water-borne outbreak broke out in Sukhumi with 21 detected cases. Low morbidity level of disease was reported during 2001-2005. Since 2006 significant increase of leptospirosis has been observed. The highest incidence was reported in 2011-1.81 per 100 000 population. The increase is likely to be mainly attributed to the improvements in diagnostics of the infection. Young and middle-age persons are more frequently vulnerable to leptospirosis in Georgia, 54.8% of the cases are reported among age group of 30-59. Incidence of the infection is the highest in males - 60-65% of the detected cases. In addition, leptospirosis is characterized by high case-fatality rate - 8.7 ± 3.6% (95% CI=5.7-11.7). Case fatality is especially high in persons over 60 and over reaching 24.3 ± 8.1%. Only single cases are observed in children under 14. In 21st century ethiological structure of leptospirosis has being changed somehow. By contrast, in the earlier period the disease was mainly caused by L. icterohaemorrhagiae and L.grippotyphosa, nowadays we encounter such causative agents which were not observed in 20th century - L. autunnalis, L. mankarso, L. wolffii and others. Water is mainly implicated as a risk factor in the infection transmission. Finally, to study of epidemiological characteristics of leptospirosis in Georgia, identified that, the infection is widely distributed in the country, has an increasing tendency and duration of the disease frequently is a severe.