Download 2. History of CCHF in Albania

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.
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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
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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.
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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
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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:
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


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.
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

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
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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.
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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)
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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)
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Photos 4 + 5 (University ICU; June 8th, 2001)
6. More bleeding and aberrant clotting time manifestations
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Photo # 6 (Kukes; June 22nd, 2001)
Model cooperation with Veterinarian colleague (incorporated as team-member) in
Kukes; checking domestic animals for ticks.
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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).
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