International Journal of Infectious Diseases 18 (2014) 97–100

Short Communication

Emergence of Crimean-Congo hemorrhagic fever in Amreli Districtof Gujarat State, India, June to July 2013

Pragya D. Yadav a, Yogesh K. Gurav a, Madhulika Mistry b, Anita M. Shete a, Prasad Sarkale a,Avinash R. Deoshatwar a, Vishwa B. Unadkat b, Prasad Kokate a, Deepak Y. Patil a,Dinkar K. Raval c, Devendra T. Mourya a,*a National Institute of Virology, Microbial Containment Complex, Sus Road, Pashan, Pune 411001, Indiab Pandit Deendayal Upadhyay Medical College, Civil Hospital Campus, Rajkot, Gujarat, Indiac Health and Family Welfare Department (Epidemic Control), Commissionerate of Health, Gandhinagar, Gujarat, India

A R T I C L E I N F O

Article history:

Received 16 August 2013

Received in revised form 24 September 2013

Accepted 25 September 2013

Corresponding Editor: Eskild Petersen,

Aarhus, Denmark

Keywords:

Emerging or re-emerging diseases

Viral hemorrhagic fever

Zoonotic infections

Crimean-Congo hemorrhagic fever

CCHF

Virus

S U M M A R Y

Crimean-Congo hemorrhagic fever virus (CCHFV) etiology was detected in a family cluster (nine cases,

including two deaths) in the village of Karyana, Amreli District, and also a fatal case in the village of

Undra, Patan District, in Gujarat State, India. Anti-CCHFV IgG antibodies were detected in domestic

animals from Karyana and adjoining villages. Hyalomma ticks from households were found to be positive

for CCHF viral RNA. This confirms the emergence of CCHFV in new areas and the wide spread of this

disease in Gujarat State.

� 2013 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious

Diseases.

Contents lists available at ScienceDirect

International Journal of Infectious Diseases

jou r nal h o mep ag e: w ww .e lsev ier . co m / loc ate / i j id

Open access under CC BY-NC-SA license.

1. Introduction

Crimean-Congo hemorrhagic fever (CCHF) is a severe acutefebrile illness caused by the CCHF virus (CCHFV), with an overallcase fatality of 9–50%.1,2 CCHFV is widespread in Africa, Asia,Southeast Europe and the Middle East.1,3 CCHF was first confirmedin India during 2010–2011, in Ahmadabad, Gujarat.4 Person-to-person transmission and instances of nosocomial transmissionwere confirmed during 2010 (two cases), 2011 (eight cases), and2012 (three cases).5,6 In this article we describe a series of cases inan outbreak of CCHF occurring in Amreli District, Gujarat Stateduring June–July 2013.

* Corresponding author. Tel.: +91 20 26006201; fax: +91 20 26122669.

E-mail addresses: directorniv@gmail.com, dtmourya@gmail.com (D.T. Mourya).

1201-9712 � 2013 The Authors. Published by Elsevier Ltd on behalf of International S

http://dx.doi.org/10.1016/j.ijid.2013.09.019

2. Case report

During the period June 23 to July 25, 2013, a cluster of suspectedviral hemorrhagic fever (VHF) cases were reported in the village ofKaryana, Amreli District, Gujarat State, India. There were fourteenreported cases, of which five were fatal. The primary case (case A)was a 90-year-old man, who presented on June 23 with fever,diarrhea, blood in the stools, and severe abdominal pain. Afterinitial treatment at Amreli District Hospital, he died on June 25. Hisgrandson (age 13 years, case B) was an index case who had closecontact with case A and had a history of tick bite; he presentedwith fever on June 27. The wife of case A (age 85 years, case C) andhis three daughters-in-law (age 60 years, case D; age 45 years, caseE; age 23 years, case F) also developed fever (June 30) andhemorrhagic symptoms and signs (petechiae, per vaginal bleed-ing). Subsequently, another daughter-in-law (age 22 years, case G)and a son (age 40 years, case H) presented with fever andhemorrhagic symptoms and signs on July 2 and July 3, respectively.During the sickness period and during the funeral of case A, familymembers along with cases (B, C, D, E, F, G, H, I, J, K, L, M, and N) hadregularly visited and stayed at the residence of case A (Table 1 andFig. 1). Close family member contacts (n = 75), along with family

ociety for Infectious Diseases. Open access under CC BY-NC-SA license.

Table 1CCHFV detection in viral hemorrhagic fever cases from in Karyana and Undra village, Gujarat, India

NIV ID Case Sex Age,

years

Address Onset

date

Specimen

collection date

POD,

days

CCHF real-time

RT-PCR

(Ct value)

CCHF

RT-PCR

CCHF IgM

ELISA

Prognosis

(died/recovered)

Date of

event

NA A M 90 Karyana 23-Jun-13 NA NA NA NA NA Died 25-Jun-13

NIV1310777 B M 13 Karyana 27-Jun-13 8-Jul-13 11 Positive (38) Positive Positive Recovered 19-Jul-13

NA C F 85 Karyana 30-Jun-13 NA NA NA NA NA Died 2-Jul-13

NIV1310780 D F 60 Karyana 30-Jun-13 6-Jul-13 6 Positive (22.5) Positive Negative Died 6-Jul-13

NIV1310779 E F 45 Karyana 30-Jun-13 7-Jul-13 7 Positive (29.7) Positive Positive Recovered 17-Jul-13

NA F F 23 Karyana 30-Jun-13 NA NA NA NA NA Died 4-Jul-13

NIV1310778 G F 22 Karyana 2-Jul-13 8-Jul-13 6 Positive (32.5) Positive Positive Recovered 19-Jul-13

NIV1310776 H M 40 Karyana 3-Jul-13 7-Jul-13 4 Positive (22.5) Positive Negative Died 9-Jul-13

NIV1311991 I F 35 Karyana 2-Jul-13 24-Jul-13 22 Negative Negative Negative Recovered 29-Jul-13

NIV1310806 J M 23 Karyana 7-Jul-13 9-Jul-13 2 Positive (21.5) Positive Negative Recovered 23-Jul-13

NIV1311122 K F 50 Karyana 8-Jul-13 15-Jul-13 7 Positive (29) Positive Negative Recovered 27-Jul-13

NIV1310923 L M 45 Karyana 8-Jul-13 11-Jul-13 3 Negative Negative Negative Recovered 19-Jul-13

NIV1311437 M F 50 Karyana 10-Jul-13 16-Jul-13 6 Positive (29.5) Positive Negative Recovered 26-Jul-13

NIV1311581 N F 35 Karyana 16-Jul-13 20-Jul-13 4 Positive (30) Positive ND Recovered 31-Jul-13

NIV1311579 O F 68 Undra (Patan) 11-Jul-13 18-Jul-13 7 Positive (30.4) Positive Negative Died 20-Jul-13

CCHFV, Crimean-Congo hemorrhagic fever virus; NIV, National Institute of Virology; POD, post-onset day of testing the serum; Ct, cycle threshold; M, male; F, female; NA,

sample not available; ND, not done.

P.D. Yadav et al. / International Journal of Infectious Diseases 18 (2014) 97–10098

relatives (n = 280), had stayed briefly in the house of the primarycase during the funeral and other rituals following his death(Fig. 1). The secondary attack rate was 3.7% and the primary attackrate was 0.3%.

Figure 1. Geographical distribution of Crimean-Congo hemorrhagic fever cases in

Case C died on post-onset day 2 due to cardio-respiratory arrestand case F died on post-onset day 4 due to hemorrhagic shock.Serum samples from suspected VHF cases were tested for dengueNS1 and IgM antibody and were referred to the National Institute

the villages of Karyana, Amreli District, and Undra, Patan District, in Gujarat.

Table 2Anti-CCHFV IgG antibody positivity in animals from Karyana village in Amreli,

Gujarat, India

Village Animal Total tested IgG positive % Positivity

Karyana Cattle 23 10 43.7

Goats 4 4 100

Sheep 6 6 100

Total 33 20 60.6

Khambala Buffalo 3 0 0

Cattle 4 2 50

Goats 8 3 37.5

Sheep 5 3 60

Total 20 8 40

Nilwada Cattle 5 2 40

Goats 16 6 37.5

Sheep 8 0 0

Total 29 8 27.5

Grand total 82 36 43.9

CCHFV, Crimean-Congo hemorrhagic fever virus.

P.D. Yadav et al. / International Journal of Infectious Diseases 18 (2014) 97–100 99

of Virology (NIV), Pune for investigation of the etiology. Bloodsamples were collected from VHF (n = 11) and fever cases (n = 26)reported in the village of Karyana during this period. The clinicalsample from a VHF case (case O) in the village of Undra, PatanDistrict was also referred to the NIV, Pune (Fig. 1).

The clinical features observed in VHF patients included high-grade fever, headache, body aches, malaise, diarrhea, abdominalpain, nausea, vomiting, petechiae, ecchymosis, bleeding perrectum and per vagina, and hematemesis, as reported previous-ly.4,5 The laboratory findings of VHF patients were elevatedprothrombin time (PT), activated partial thromboplastin time(aPTT), alanine aminotransferase (ALT), aspartate aminotransfer-ase (AST), lactate dehydrogenase (LDH), and creatine phosphoki-nase (CPK), leukopenia, and thrombocytopenia, as well assignificantly raised fibrinogen degradation products (FDP) andD-dimer levels.

Samples from domestic animals (cattle, sheep, and goats) andinfested ticks from the vicinity of the index case (case A) (Karyanaand neighboring villages) were collected by the authorities of theAnimal Husbandry Department and National Vector Borne DiseaseControl Programme (NVBDCP) (Table 2). A total of 138 ticks werecollected from Karyana, 94 from Nilwada, and 139 from Khambalaand were classified and pooled in 30 groups (SupplementaryMaterial, Table S1).

Human, tick, and animal samples were processed in a biosafetylevel 4 laboratory at NIV, Pune and tested for CCHFV and KyasanurForest disease virus by real-time RT-PCR, RT-PCR, and IgM ELISA.5–9

The CCHFV etiology was confirmed in 10 cases (three deaths),including the fatal case from Patan District (Fig. 1). Serum samplescollected from fever cases (n = 26) were found negative for CCHFV,while anti-dengue IgM antibodies were detected in two fever cases.

Hyalomma anatolicum anatolicum pools (n = 5) collected fromlivestock around the village of Karyana were found positive by RT-PCR and real-time RT-PCR. Livestock blood samples (n = 95) werefound negative for CCHFV. A 226-bp fragment of the S segmentgenerated from CCHF-positive human samples and tick poolsshowed that the CCHFV detected in Karyana had maximumnucleotide identity (99.0%) with the Ahmadabad strain of the 2011outbreak sequences and belongs to Asian/Middle East geneticlineage IV.5–7 CCHFV-specific IgG positivity was found in livestock(cattle, goats, and sheep) from the villages of Karyana, Nilwada,and Khambala (Table 2). The overall IgG antibody positivity in theanimals was 43.9%.

3. Discussion

The likely source of the CCHF identified in the village ofKaryana, Amreli District was virus-infected Hyalomma ticks and

livestock at the residence of the primary case (case A). Domesticanimal positivity for IgG antibodies in Karyana and surroundingvillages and the human case positivity in Patan District confirmsthat CCHF is widely present in this region. The presence of anti-dengue IgM antibodies among fever cases reported in the villagealso confirms the underlying dengue activity in the area. Theisolation of human cases, treatment in hospital by institutingribavirin timely replacement of blood components, universalprecautions, contact tracing and surveillance of fever cases andinsecticidal spray as an anti-tick measure, initiated in the affectedvillage and neighboring villages, helped to contain the focaloutbreak.

Acknowledgements

We gratefully acknowledge the encouragement and supportextended by Dr V.M. Katoch, Secretary, Department of HealthResearch, New Delhi, during our investigations. We also appreciatethe cooperation of the Directorate of Health Services, Governmentof Gujarat, and the Hospital Authorities of PDU Medical College,especially Dr Yogesh Goswami, Head of the Department ofMicrobiology, Gujarat. We are thankful to Dr V.S. Dhruwey (StateSurveillance Officer, Integrated Disease Surveillance Programme),Dr G.C. Patel (State Epidemiologist), Dr Kamalesh Upadhyay(Professor, Medicine, BJMC, Ahmadabad), Dr K.P. Patel (ChiefDistrict Health Officer, Amreli), and Dr B.V. Tandale (Scientist D,NIV Pune) for their cooperation, Dr P.T. Joshi (ConsultantEntomologist, National Vector Borne Disease Control Programme,Gandhinagar, Gujarat) for the collection of ticks, and Dr M.D.Gokhale (Scientist B, NIV Pune) for the identification of ticks. Wealso gratefully acknowledge Dr Stuart Nichol, CDC, Atlanta, USA forproviding the serological kit for the detection of IgG antibodies inanimals. We thank Mr Rajen Lakra, Mr Sanjay Gopale, Ms DivyaZawar, and Ms Linata Patil for technical support.

Conflict of interest: The authors declare no conflicts of interest.Financial support was provided by the National Institute ofVirology, Pune, India.

Ethical approval: Although this was an outbreak investigation,the institutional human ethics committee and institutionalbiosafety committee were informed. Informed consent wasobtained from the patients or their relatives in English or thelocal language Gujarati. The confidentiality of the cases and thecontact case names and details has been maintained.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, inthe online version, at http://dx.doi.org/10.1016/j.ijid.2013.09.019.

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