Skip directly to site content Skip directly to page options Skip directly to A-Z link Skip directly to A-Z link Skip directly to A-Z link
Volume 21, Number 1—January 2015

Health Care Response to CCHF in US Soldier and Nosocomial Transmission to Health Care Providers, Germany, 2009

Nicholas G. CongerComments to Author , Kristopher M. Paolino, Erik C. Osborn, Janice M. Rusnak, Stephan Günther, Jane Pool, Pierre E. Rollin, Patrick F. Allan, Jonas Schmidt-Chanasit, Toni Rieger, and Mark G. Kortepeter1
Author affiliations: Landstuhl Regional Medical Center, Landstuhl, Germany (N.G. Conger, E.C. Osborn, J. Pool, P.F. Allan); Walter Reed Army Institute of Research, Silver Spring, Maryland, USA (K.M. Paolino); Force Health Protection, Fort Detrick, Maryland, USA (J.M. Rusnak); Bernard Nocht Institute, Hamburg, Germany (S. Günther, J. Schmidt-Chanasit, T. Rieger); Centers for Disease Control and Prevention, Atlanta, Georgia, USA (P. Rollin); Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA (M.G. Kortepeter)

Main Article

Table 3

Surveillance criteria and PEP, by exposure risk, for contacts of US soldier with fatal Crimean–Congo hemorrhagic fever, Germany, 2009*

Group no. No persons Risk PEP and monitoring
Contact of skin or mucous membranes with contaminated blood or body fluids; present during bronchoscopy or during use of bag-valve-mask ventilation device (risk of aerosolization of infectious blood/body fluids likely) and without proper PPE†
Oral ribavirin PEP offered; baseline and at least weekly chemistries and CBC; CCHF acute/convalescentphase titers‡; monitoring for fever (twice daily) and for CCHF symptoms and medication side effects (for 15 d in clinic)
Present during bronchoscopy or during use of bag-valve-mask ventilation device (even with proper PPE)†; known contact with contaminated blood or body fluids but wore proper PPE and without PPE breaches† (no known mucosal or skin contact with infectious blood/body fluids); laboratory workers who performed tests on specimens (removed specimens from container) and wore proper PPE†
Monitoring for fever twice daily for 15 d (in clinic); self-observation and reporting of signs or symptoms e.g., fever) for 15 d
3 41 Persons in patient’s room who wore proper PPE and without PPE breaches and no contact with infectious blood/body fluids†; laboratory workers who handled laboratory specimens (but did not remove specimens from container) and wore proper PPE† No active monitoring; self-observation and reporting of signs or symptoms (e.g., fever) for 15 d

*CBC, complete blood count; CCHF, Crimean–Congo hemorrhagic fever; PEP, postexposure prophylaxis; PPE, personal protective equipment.
†Proper PPE for aerosol exposure included gown, gloves, N95 respirator, and protective eyewear; powered air-purifying respirators and full biohazard suits were required during bronchoscopies and chest tube placements by physician performing the procedure.
‡ELISA for CCHF-specific IgM and IgG performed at the Centers for Disease Control and Prevention, Atlanta, Georgia, USA (11).

Main Article

  1. Bente  DA, Forrester  NL, Watts  DM, McAuley  AJ, Whitehouse  CA. Crimean–Congo hemorrhagic fever: history, epidemiology, pathogenesis, clinical syndrome and genetic diversity. Antiviral Res. 2013;100:15989. DOIPubMedGoogle Scholar
  2. Erby  A. Crimean–Congo hemorrhagic fever virus. In: Dongyou Liu, editor. Manual of security sensitive microbes and toxins. Boca Raton (FL): CRC Press; 2014. p. 37–52.
  3. Rusnak  JM. Experience with ribavirin for treatment and postexposure prophylaxis of hemorrhagic fever viruses: Crimean Congo hemorrhagic fever, Lassa fever, and hantavirus [cited 2014 Sep 15].
  4. Swanepoel  R, Gill  DE, Shepherd  AJ, Leman  PA, Mynhardt  JH, Harvey  S. The clinical pathology of Crimean–Congo hemorrhagic fever. Rev Infect Dis. 1989;11:S794800. DOIPubMedGoogle Scholar
  5. Karti  SS, Odabasi  Z, Korten  V, Yilmaz  M, Sonmez  M, Caylan  R, Crimean–Congo hemorrhagic fever in Turkey. Emerg Infect Dis. 2004;10:137984. DOIPubMedGoogle Scholar
  6. Wölfel  R, Paweska  JT, Petersen  N, Grobbelaar  AA, Leman  PA, Hewson  R, Virus detection and monitoring of viral load in Crimean–Congo hemorrhagic fever virus patients. Emerg Infect Dis. 2007;13:1097100. DOIPubMedGoogle Scholar
  7. Lambert  AJ, Lanciotti  RS. Consensus amplification and novel multiplex sequencing method for S segment species identification of 47 viruses of the Orthobunyavirus, Phlebovirus, and Nairovirus genera of the family Bunyaviridae. J Clin Microbiol. 2009;47:2398404. DOIPubMedGoogle Scholar
  8. Olschläger  S, Gabriel  M, Schmidt-Chanasit  J, Meyer  M, Osborn  E, Conger  NG, Complete sequence and phylogenetic characterisation of Crimean-Congo hemorrhagic fever virus from Afghanistan. J Clin Virol. 2011;50:902. DOIPubMedGoogle Scholar
  9. Centers for Disease Control and Prevention (CDC). Interim guidance for managing patients with suspected viral hemorrhagic fever in US Hospitals; 2005 19 May [cited 2014 Sept 11].
  10. World Health Organization. Application for inclusion of ribavirin in the WHO model list of essential medicines [2010 Sep 15].
  11. Khan  AS, Maupin  GO, Rollin  PE, Noor  AM, Shurie  HHM, Shalabi  AGA, An outbreak of Crimean–Congo hemorrhagic fever in the United Arab Emirates, 1994–1995. Am J Trop Med Hyg. 1997;57:51925 .PubMedGoogle Scholar
  12. Burney  MI, Ghafoor  A, Saleen  M, Webb  PA, Casals  J. Nosocomial outbreak of viral hemorrhagic fever caused by Crimean hemorrhagic fever–Congo virus in Pakistan, January 1976. Am J Trop Med Hyg. 1980;29:9417 .PubMedGoogle Scholar
  13. Amorosa  V, MacNeil  A, McConnell  R, Patel  A, Dillon  KE, Hamilton  K, Imported Lassa fever, Pennsylvania, USA, 2010. Emerg Infect Dis. 2010;16:1598600. DOIPubMedGoogle Scholar
  14. Jauréguiberry  S, Tattevin  P, Tarantola  A, Legay  F, Tall  A, Nabeth  P, Imported Crimean–Congo hemorrhagic fever. J Clin Microbiol. 2005;43:49057. DOIPubMedGoogle Scholar
  15. Barry  M, Russi  M, Armstrong  L, Geller  D, Tesh  R, Dembry  L, Treatment of a laboratory-acquired Sabia virus infection. N Engl J Med. 1995;333:2946. DOIPubMedGoogle Scholar
  16. Timen  A, Koopmans  MP, Vossen  AC, van Doornum  GJ, Gunther  S, van den Berkmortel  F, Response to imported case of Marburg hemorrhagic fever, the Netherlands. Emerg Infect Dis. 2009;15:11715. DOIPubMedGoogle Scholar
  17. World Health Organization. Global alert and response (GAR). Ebola virus disease, West – update. 2014 Jul 27[cited 4 Aug 2014].
  18. Bhagat  CI, Lewer  M, Prins  A, Beilby  JP. Effects of heating plasma at 56 degrees C for 30 min and at 60 degrees C for 60 min on routine biochemistry analytes. Ann Clin Biochem. 2000;37:8024. DOIPubMedGoogle Scholar
  19. Bodur  H, Akinci  E, Onguru  P, Carhan  A, Uyar  Y, Tanrici  A, Detection of Crimean–Congo hemorrhagic fever virus genome in saliva and urine. Int J Infect Dis. 2010;14:e2479. DOIPubMedGoogle Scholar
  20. Thomas  S, Thomson  G, Dowall  S, Bruce  C, Cook  N, Easterbrook  L, Review of Crimean Congo hemorrhagic fever infection in Kosova in 2008 and 2009: prolonged viremias and virus detected in urine by PCR. Vector Borne Zoonotic Dis. 2012;12:8004. DOIPubMedGoogle Scholar
  21. Keshtkar-Jahromi  M, Sajadi  MM, Ansari  H, Mardani  M, Holakouie-Naieni  K. Crimean–Congo hemorrhagic fever in Iran. Antiviral Res. 2013;100:208. DOIPubMedGoogle Scholar
  22. Bodur  H, Akinci  E, Ascioglu  S, Onguru  P, Uyar  Y. Subclinical infection with Crimean–Congo hemorrhagic fever virus, Turkey. Emerg Infect Dis. 2012;18:6402. DOIPubMedGoogle Scholar
  23. Ozturk  B, Tutuncu  E, Kuscu  F, Gurbuz  Y, Sencan  I, Tuzun  H. Evaluation of factors predictive of the prognosis in Crimean–Congo hemorrhagic fever: new suggestions. Int J Infect Dis. 2012;16:e8993. DOIPubMedGoogle Scholar
  24. Hatipoglu  CA, Bulut  C, Yetkin  MA, Ertem  GT, Erdinc  FS, Kilic  EI, Evaluation of clinical and laboratory predictors of fatality in patients with Crimean–Congo haemorrhagic fever in a tertiary care hospital in Turkey. Scand J Infect Dis. 2010;42:51621. DOIPubMedGoogle Scholar
  25. Çevik  MA, Erbay  A, Bodur  H, Gulderen  E, Bastug  A, Kubar  A, Clinical and laboratory features of Crimean–Congo hemorrhagic fever: predictors of fatality. Int J Infect Dis. 2008;12:3749. DOIPubMedGoogle Scholar
  26. Ozbey  SB, Kader  C, Erbay  A, Ergonul  O. Early use of ribavirin is beneficial in Crimean–Congo hemorrhagic fever. Vector Borne Zoonotic Dis. 2014;14:3002. DOIPubMedGoogle Scholar
  27. Onguru  P, Dagdas  S, Bodur  H, Yilmaz  M, Akinci  E, Eren  S, Coagulopathy parameters in patients with Crimean–Congo hemorrhagic fever and its relation with mortality. J Clin Lab Anal. 2010;24:1636. DOIPubMedGoogle Scholar
  28. Saksida  A, Duh  D, Wraber  B, Dedushaj  I, Ahmeti  S, Avsic-Zupanc  T. Interacting roles of immune mechanisms and viral load in the pathogenesis of Crimean–Congo hemorrhagic fever. Clin Vaccine Immunol. 2010;17:108693. DOIPubMedGoogle Scholar
  29. Connolly-Andersen  AM, Moll  G, Andersson  C, Akerström  S, Karlberg  H, Douagi  I, Crimean–Congo hemorrhagic fever virus activates endothelial cells. J Virol. 2011;85:776674. DOIPubMedGoogle Scholar
  30. Weber  F, Mirazimi  A. Interferon and cytokine responses to Crimean Congo hemorrhagic fever virus; an emerging and neglected viral zoonosis. Cytokine Growth Factor Rev. 2008;19:395404. DOIPubMedGoogle Scholar
  31. Ergonul  O, Tuncbilek  S, Baykam  N, Celikbas  A, Dokuzoguz  B. Evaluation of serum levels of interleukin (IL)-6, IL-10 and tumor necrosis factor-α in patients with Crimean–Congo hemorrhagic fever. J Infect Dis. 2006;193:9414. DOIPubMedGoogle Scholar
  32. Papa  A, Bino  S, Velo  E, Harxhi  A, Kota  M, Antoniadis  A. Cytokine levels in Crimean–Congo hemorrhagic fever. J Clin Virol. 2006;36:2726. DOIPubMedGoogle Scholar
  33. Ozturk  B, Kuscu  F, Tutuncu  E, Sencan  I, Gurbuz  Y, Tuzan  H. Evaluation of the association of serum levels of hyaluronic acid, sICAM-1, sVCAM-1, and VEGF-A with mortality and prognosis in patients with Crimean–Congo hemorrhagic fever. J Clin Virol. 2010;47:1159. DOIPubMedGoogle Scholar
  34. Peyrefitte  CN, Perret  M, Garcia  S, Rodriguez  R, Bagnaud  A, Lacote  S, Differential activation profiles of Crimean–Congo hemorrhagic fever virus– and Dugbe virus–infected antigen-presenting cells. J Gen Virol. 2010;91:18998. DOIPubMedGoogle Scholar
  35. Bodur  H, Akinci  E, Onguru  P, Uyar  Y, Basturk  B, Gozel  MG, Evidence of vascular endothelial damage in Crimean–Congo hemorrhagic fever. Int J Infect Dis. 2010;14:e7047. DOIPubMedGoogle Scholar
  36. Bakir  M, Bakir  S, Sari  I, Celik  VK, Gozel  MG, Engin  A. Evaluation of the relationship between serum levels of VEGF and sVEGFR1 with mortality and prognosis in patients with Crimean–Congo hemorrhagic fever. J Med Virol. 2013;85:1794801. DOIPubMedGoogle Scholar
  37. van Paassen  J, Bauer  MP, Arbous  MS, Visser  LG, Schmidt-Chanasit  J, Schilling  S, Acute liver failure, multiorgan failure, cerebral oedema, and activation of proangiogenic and antiangiogenic factors in a case of Marburg haemorrhagic fever. Lancet Infect Dis. 2012;12:63542. DOIPubMedGoogle Scholar
  38. Andersson  I, Lundkvist  A, Haller  O, Mirazimi  A. Type I interferon inhibits Crimean–Congo hemorrhagic fever virus in human target cells. J Med Virol. 2006;78:21622. DOIPubMedGoogle Scholar
  39. Andersson  I, Karlberg  H, Mousari-Jazi  M, Martinez-Sobrido  L, Wever  F, Mirazimi  A. Crimean–Congo hemorrhagic fever virus delays activation of the innate immune response. J Med Virol. 2008;80:1397404. DOIPubMedGoogle Scholar
  40. Oestereich  L, Rieger  T, Neumann  M, Bernreuther  C, Lehmann  M, Krasemann  S, Evaluation of antiviral efficacy of ribavirin, arbidol, and T-705 (favipiravir) in a mouse model for Crimean–Congo hemorrhagic fever. PLoS Negl Trop Dis. 2014;8:e2804. DOIPubMedGoogle Scholar

Main Article

1Preliminary results from this study were presented at the Annual Meeting of the Armed Forces Infectious Disease Society; May 23, 2010, San Antonio, Texas, USA; NATO Biomedical Advisory; May 27, 2010, Munich, Germany; and Asian Pacific Military Medicine Conference, May 3, 2011, Sydney, New South Wales, Australia.

Page created: December 17, 2014
Page updated: December 17, 2014
Page reviewed: December 17, 2014
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.