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World Health Organization WHO EHA Office in Albania Tirana Office Report Rapid Assessment of Haemorragic Fever situation in Kukes, related to the CCHF Outbreak in Kosovo. June 2001 Survey Team: Ardian Xinxo (WHOAlbania), Adela Llagami (IPH), Miranda Hajdini (IPH), Brigitte Helynck (InVS) SUPPORTED BY WHO ALBANIA 1. Outbreak Notification On May 29, a suspected case of haemorrhagic fever (HF) was reported from Kukes District. The Institute of Public Health (IPH) sent an epidemiologist to investigate the case and take blood samples for further diagnostic tests. A second case, referred from Kukes to Tirana (University Infectious Disease Hospital ICU) on June 4 th was suspicious for HF. Blood samples of theses two (2) cases were sent by the IPH to Dr. Antonis Antoniades at the WHO Collaborating Centre of the Microbiology Department of the Aristoteleian University’s Medical College in Thessaloniki, Greece. On June 12th we were notified that the two suspected cases’ samples were positive for CCHF (titers of 1:128 and 1:64). All household contacts tested negative. They had additionally been tested for hantaviruses (spot slides with Hantaan and Puumala antigen) as well as Leptospira for which they were found negative though PCR was pending. On June 15th, 2001, two (2) more suspected cases were reported in Kukes, in the north-eastern part of the country and bordering Kosovo. From June 21 to 28, 2001, a WHO Albania Public Health Officer led a team consisting of two IPH and one Institut de Veille Sanitaire (Paris) epidemiologists to Kukes to assess the situation. The team also went to Pristina for one day to meet the team in charge of the CCHF outbreak in Kosovo in a cross-border collaborative effort. This report contains an assessment of the situation and recommendations. 2. History of CCHF in Albania CCHF is a viral haemorrhagic fever of the Nairovirus group. Although primarily a zoonosis, sporadic cases and outbreaks of CCHF affecting humans do occur. The geographical distribution of the virus, like that of the tick vector, is widespread. Among others, CCHF is endemic in Eastern Europe and the Balkans – and as the name indicates, Congo and Crimea. Haemorragic Fever situation in Albania 29/06/2001 1 In Albania, an outbreak of haemorrhagic fever (CCHF and hantavirus) was described in 1986-1987, and again in 1989. Since 1990, sporadic cases of haemorrhagic fever (HF) have been reported each year. The following data were obtained from the Epidemiology Office in Kukes (Table 1). TABLE 1: NUMBER OF HAEMORRHAGIC FEVER CASES REPORTED IN KUKES DISTRICT, (1993 – 2000). 1997 Number of reported Period of cases of HF occurrence Qershor –Shtator 7 June – September Maj – Qershor 3 May – July Mars 1 March Qershor - Gusht 2 June – August 0 1998 1 1999 0 2000 0 Year 1993 1994 1995 1996 Qershor June - - Source: Epidemiologist Office in Kukes The chief of the Paediatrics Infectious Diseases Ward in Kukes confirmed that HF is endemic in the area (Pobrec, Bardhoc, Morin, Shtiqen, Nang, Surroj, Ujmisht, Kalimash, Shumri, Helshan, Golaj, Tregtan, Gjinaj), averaging 10 to 15 cases each year, and no reported cases over the last two years. Patients usually come from villages but also from Kukes city. Patients are managed in Kukes hospital, except for when they develop renal failure and are referred to Tirana. No nosocomial cases and no deaths have been reported. During 2001, no cases of HF were reported through the weekly national surveillance system implemented by WHO (ALERT). 3. Current Outbreak Status: 3.1. Description of first cases Case # 1: A 66 year-old woman from the rural village of Koder Lume, Kukës District. She owns cattle which have been examined and found to harbour ticks – see attached Photo # 6. She became ill and was hospitalised on May 20, with fever and vomiting, initially diagnosed as “toxic-infection”. During hospitalisation she had hematemesis presumed to be due to a “stomach ulcer”. A tick was eventually discovered in her inguinal area, and Haemorrhagic Fever entered the differential Haemorragic Fever situation in Albania 29/06/2001 2 diagnosis list. A blood sample taken on May 28th tested positive for CCHF on June 12th – see above. Case # 2: A 25 year-old male nurse from Kukes working at Kukes Hospital. He lives in a flat in town and has no animals at home nor any contact with animals. While performing an ECG for Case # 1 above he was exposed to aerosolised material from her diffuse gingival bleeding. He subsequently became ill and was hospitalised on May 27th with an acute febrile syndrome. He deteriorated and developed haemorrhage and coma and was helicoptered to the University of Tirana Infectious Disease Hospital’s ICU on May 31st. A blood sample was taken on June 4 th and tested positive for CCHF on June 12th, 2001 (see above). Suspected Case # 3: A nine (9) year old boy from the village of Koder Lume in Kukës District. He lives in a house in the village and his family owns cattle found to harbour ticks. No ticks have been found on his skin but two insect bites were visible on his neck. Onset of symptoms was June 12 th, with fever, abdominal pain, and fatigue. Nose bleeding and hematemesis ensued and was hospitalised on June 15 th. The first blood sample was haemolyse and a second one was retaken on June 23 rd. Results are pending. Suspected Case # 4: An eight (8) year old boy from the village of Nang, Kukës District. He lives in a house in the village and no ticks or insect bites have been found on his skin. Onset of disease and hospitalisation were on June 15 th, with fever, headache, and purpural spots. First blood sample was found to have haemolysed and a second was taken on June 22nd. Results are pending. Suspected Case # 5: A 23 year old woman from the village of Helshan, Has District. She lives in house in the village and keeps animals at home found to have ticks. No tick or insect bites were found on her body. Onset of disease was on June 20th, with fever, shivers, lower back pain, vomiting, though no haemorrhagic signs. A blood sample taken on June 28; results are pending. Suspected Case # 6: A 27 year old woman from the village of Shtiqen, Kukës District. She lives in a house in the village and her domestic animalswere not found to carry ticks. No tick or insect-bites were found on her body. Onset of symptoms was June 24th with fever, shivers, fatigue, conjunctival hyperemia (only for one day) and petechiae. A blood sample taken on June 28th; results are pending. Haemorragic Fever situation in Albania 29/06/2001 3 Suspected Case # 7: A 35 year old woman from the village of Bregë Lumë, Kukës District who lives in a village house; her domestic animals have no ticks. No tick or other bites have been discovered on her body. Onset of illness was on June 24 th, with fever, vomiting and purpura. A blood sample taken on June 28; results are pending. Suspected Case # 8: A 30 year old man from the village of Tregtan, Has District. He lives in a house in the village and keeps domestic animals not found to have ticks. No tick or insect-bites were found on his body. He reports having travelled to Gjakova (Kosova) on June 25th. Onset of illness was June 26th, with fever, headache, shivers, vomiting; no haemorhagic signs. A blood sample was taken on June 28th with results pending. 3.2. Analysis by Time, Place, Person CASES OF CCHF BY TYPE, AS ON JUNE 28, 2001 CASES | Freq. Pourcent Cum. ---------------+----------------------POSSIBLE | 2 25.0% 75.0% SUSPECTED | 4 50.0% 50.0% CONFIRMED | 2 25.0% 100.0% Suspected and Confirmed Cases of Congo-Crimea Hemorrhagic Fever by Date of Onset Albania, May-June 2001 1 possible case 1 suspected case 1 confirmed case Number of cases 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Week Number, 2001 ---------------+----------------------Total | 8 100.0% CASES BY AGE GROUP, AS ON JUNE 28, 2001 RASTI AGEGRP | POSSIBLE SUSPECTED CONFIRMED | Total --------------+-------------------------------------+-----00-14 | 0 2 0 | 2 15-44 | 2 2 1 | 5 45+ | 0 0 1 | 1 --------------+-------------------------------------+-----Total | 2 4 2 | 8 Haemorragic Fever situation in Albania 29/06/2001 4 CASES BY VILLAGE, AS ON JUNE 28, 2001 RASTI QYTETIFSHA | POSSIBLE SUSPECTED CONFIRMED | Total --------------+-------------------------------------+-----BREG LUMA | 0 1 0 | 1 HELSHAN | 1 0 0 | 1 KODER LUMA | 0 1 1 | 2 NANG | 0 1 0 | 1 QYTET | 0 0 1 | 1 SHTIQEN | 0 1 0 | 1 TREGTAN | 1 0 0 | 1 --------------+-------------------------------------+-----Total | 2 4 2 | 8 4. Assessment and Recommendations for response intervention 4.1. Surveillance and Epidemiology Problems observed with the ALERT surveillance system: ALERT relies for its function and validity on family doctors who are theoretically the entry point in the health system. In reality patients refer themselves directly to the hospital and especially regarding perceived “serious” problems. None of the eight (8) cases above was reported through a family doctor and thus were not picked up by ALERT. ALERT data, when available, are transmitted to the IPH; no preliminary local data analysis is performed. Outbreak response and preparedness need to be formalised with specific guidelines developed regarding : case definitions for active case-finding, contact tracing, standard forms for case and contacts recording etc. An FETP-type environment and activities must be created. Specific problems observed in Kukes: Connections and relationships within the different links along the chain of primary health care, and between primary health care providers and the hospital are not optimal nor cooperative: The current acting district epidemiologist has not been officially appointed. Though she exhibited a willingness to learn and participate she has had no formal training nor experience in epidemiology. There is a discrepancy over the last few years between the number of HF cases hospitalised and notification of HF cases to the district epidemiology department. The emergency unit of Kukes hospital does not participate as a reporting unit for ALERT and its register is not useful for retroactive case finding since clinical signs and treatment are not registered. During such outbreaks it should be emergently rendered as a sentinel surveillance unit for ALERT. The public health laboratory is not yet involved in surveillance and response. It has no protocol for collection and transport of samples (Public Health Laboratories rehabilitation, training, and incorporation in ALERT is a proposed future project by WHO Albania). Specific problems observed in Has: Primary Health Care has been inactive: Haemorragic Fever situation in Albania 29/06/2001 5 Four out of the five family doctors (including the epidemiologist) have been working parttime for an NGO during the time of the outbreak; only one was present on the day of the visit. Patients usually go directly to Kukes for serious health problem. The outpatient register here was also useless (as in Kukes) for retroactive case finding since clinical signs and treatments were also not registered. Actions taken: Case definitions have been developed for the investigation of the HF outbreak, as well as standard forms for case recording and contact follow-up (annex). The process for the preparation of guidelines for district epidemiologists and family doctors was initiated and materials prepared were based on those used in Kosovo - as well as CDC and WHO documents. Regrettably no such materials had been prepared nor distributed by the IPH well into the outbreak. Recommendations: Forms, protocols and guidelines must be rapidly finalised and disseminated to districts epidemiologists and family doctors. The district epidemiologist in Kukes needs to be officially appointed and trained. During an outbreak, the district epidemiologist needs to everyday check the hospital emergency unit register for possible or suspected cases. Data of HF must be analysed locally: mapped with focal points, epidemiologic curves, standard analyses. The same analyses must be conducted at central level. The district epidemiologist, with support from the IPH should organise meetings for family doctors of Kukes, Has and Tropojë districts in order to inform them about CCHF, furnish them with working case definitions, reinforce motivation for active surveillance, explain the importance of contacts’ follow-up etc. This meeting should also involve nurses in charge of epidemiology at the commune level, and hospital doctors (infectious disease departments and emergency unit). Files must be organised properly in order to mount an appropriate response and for documentation. Guidelines for processing, labelling and transport of specimens must be elaborated for the district laboratory. A timely feed-back should be implemented from the IPH to the district epidemiologist and from district epidemiologist to hospitals, to inform on individual laboratory results and on the global outbreak course, including information from Kosovo. 4.2. Case management in hospital setting The team found the hospital-wide conditions and practices as not adequate to ensure safety of the staff and other patients admitted in Kukes hospital. At the time of their admission cases #3 and #4 were in separate room in the Paediatrics Infectious Disease Ward. No specific staff was assigned to them. Nurses wore protective gowns, masks and gloves to take blood from patients, but needles and other waste were discharged in open buckets in the corridor. “Universal Precautions” principles were neither known nor instinctively followed. Actions taken: The issue of security in the management of the cases has been discussed with the hospital director and the infectious disease physicians. Haemorragic Fever situation in Albania 29/06/2001 6 We requested setting up an isolation ward and the implementation of strict isolation practices to prevent further nosocomial transmission of the disease (as in the case of Case # 1). Protocols and guidelines are under preparation, based on materials used in Kosovo as well as CDC and WHO documents. Recommendations: Protocols and guidelines must be rapidly finalised and disseminated to health care settings. Case definitions must be made available in the hospital setting and used to organise the wards for possible, suspected, and confirmed cases. Adequate equipment must be made available. Inspection and verification visits must be conducted to check on proper implementation of the instructions, with priority to Kukes and Tirana hospitals. 4.3. Information and communication A Health Alert re HF has been sent to all districts by ISHP/MoH. Unfortunately, no follow-up materials or instructions regarding case management etc. were subsequently sent. In Kukes, special TV and radio programmes have been broadcasted the beginning of June. Recommendations: Prepare and disseminate specific leaflets on HF for both population at risk and health-care workers in concerned areas. Repeat TV and radio programs on HF. 4.4. Actions from the central level A co-ordination committee of all involved parties is necessary in order to ensure effective preparedness and response to the HF outbreak. The committee should receive timely information from the IPH Epidemiology Department in order to take all subsequent dictated and needed actions. A joint team from Ministry of Health and IPH should go to Kukes in order to ensure that proper actions are implemented and to set up a district co-ordination committee to enhance collaboration between the Hospital and the Public Health Department. Collaboration should also include veterinary services at district and central level. Contact with the IPH of Kosovo must continue. At the end of the outbreak IPH should make a complete study report and ensure the collection of all data, forms, leaflets, photos, reports, any document and electronic files, as part of feed back and in order to build on this experience and recruit it in the management of future occurrences. Persons interviewed by the survey team: In Kukes: Shefqet Kumanova, Director of Public Health Bajram Cenaj, Director of Primary Health Care Shkëlqime Tobli, District Epidemiologist Filxhane Murati, Vice Epidemiologist Haemorragic Fever situation in Albania 29/06/2001 7 Adem Allaçi, Veterinaryian Xhemali Peposhi, Head of Paediatrics Infectious Diseases Ward, Kukes Hospital Head of Infectious Diseases Ward, Kukes Hospital Director of Kukes Hospital In Pristina: Skënder Boshnjaku, Director of IPH Isuf Dedushaj, Chief of Epidemiology Department Sali Ahmeti, Chief of Infectious Diseases Department Tritan Kalo, UNMIK Mathias Reinicke, WHO Gail Thomson, WHO Percaktimi i rastit Case definitions Tre nivelet e Përcaktimit të Rastit për Ethen Hemorragjike (EH) (Pacientët nga çdo rreth i Shqipërisë që paraqesin shënjat e mëposhtme, duke filluar nga 15 Maj 2001) Three levels of Hemorrhagic Fever case definition (HF) (Patient from any district in Albania who has developed the following signs, since May 15, 2001) 1. “Rast i mundshëm”: shpërthim akut i menjëhershëm i ethes së pa shpjegueshme me dhimbje koke, dhimbje mesi në pjesën e poshtme, dobësi, të vjella, dhe një histori të njohur ekspozimi ose pickimi të fundit nga rriqnat (ose brejtësve), si dhe rënie në kontakt me raste të konfirmuara të EH. Rasti i mundshëm mund të bëhet një “rast i dyshuar” (suspektuar) gjatë kursit të sëmundjes, nëse pacienti pas disa ditësh zhvillon shënja hemorragjike. “Possible case”: acute onset of unexplained fever with headache, lower back pain, weakness or vomiting and with known history of recent tick bite or possible exposure to ticks (or rodents) or contact with confirmed case. A possible case may become a suspected case during the course of the disease if the patient develops hemorrhagic signs after some days. 2. “Rast i dyshimt”: shpërthim akut i ethes me çfardolloj shënje hemorragjike (përdor ekzaktësisht përcaktimin e rastit të ALERTit) “Suspected case”: acute onset of fever with any kind of hemorrhagic sign (use exact ALERT case definition). 3. “Rast i konfirmuar”: një “rast i mundshëm” ose “rast i dyshimt” i konfirmuar nga ana laboratorike për EH. Confirmed case: possible or suspected case with HF laboratory confirmation. Haemorragic Fever situation in Albania 29/06/2001 8 Photo 1 Case # 2 (Male Nurse from Kukes Hospital infected from Case # 1) on day # 14 of his illness at the Nene Tereza University Infectious Disease Hospital’s Intensive Care Unit (June 8th, 2001) Haemorragic Fever situation in Albania 29/06/2001 9 Photo 2 (University ICU; June 8th, 2001) Photo 3 (University ICU) 5. Site of sternal bone-marrow biopsy (photo 2) with subsequent difficulty controlling the bleeding. Diffuse petechiae and subcutaneous haemorrhage (photo # 3) Haemorragic Fever situation in Albania 29/06/2001 10 Photos 4 + 5 (University ICU; June 8th, 2001) 6. More bleeding and aberrant clotting time manifestations Haemorragic Fever situation in Albania 29/06/2001 11 Photo # 6 (Kukes; June 22nd, 2001) Model cooperation with Veterinarian colleague (incorporated as team-member) in Kukes; checking domestic animals for ticks. Haemorragic Fever situation in Albania 29/06/2001 12 Photos # 7 (Kukes; June 25th, 2001) + 8 (University ICU; June 9th, 2001) Daily conference with Kukes and Institute of Public Health epidemiologists assessing the day’s findings (photo # 7). Conferring with the attending ICU Physician at the University Infectious Disease Hospital (photo # 8). Haemorragic Fever situation in Albania 29/06/2001 13