• 1

    Hoogstraal H, 1979. The epidemiology of tick-borne Crimean-Congo hemorrhagic fever in Asia, Europe, and Africa. J Med Entemol 15 :307–417.

    • Search Google Scholar
    • Export Citation
  • 2

    Leshchinskaya EV, 1965. Crimean hemorrhagic fever. Trudy Inst Polio Virus Entsef Akad Med Nauk SSSR 7 :226–236.

  • 3

    Casals J, Henderson BE, Hoogstraal H, Johnson KM, Shelokov A, 1970. A review of Soviet viral hemorrhagic fevers, 1969. J Infect Dis 122 :437–453.

    • Search Google Scholar
    • Export Citation
  • 4

    Scrimgeour EM, 1995. Communicable diseases in Saudia Arabia; an epidemiological review. Trop Dis Bull 92 :R79–R95.

  • 5

    Suleiman MN, Muscat-Baron JM, Harries JR, Satti AG, Platt GS, Bowen ET, Simpson DI, 1980. Congo/Crimean haemorrhagic fever in Dubai. An outbreak at the Rashid Hospital. Lancet 2 :939–941.

    • Search Google Scholar
    • Export Citation
  • 6

    Al-Nakib W, Lloyd G, El-Mekki A, Platt G, Beeson A, Southee T, 1984. Preliminary report on arbovirus-antibody prevalence among patients in Kuwait: evidence of Congo-Crimean virus infection. Trans R Soc Trop Med Hyg 78 :474–476.

    • Search Google Scholar
    • Export Citation
  • 7

    Al-Tikriti SK, Al-Ani F, Jurji FJ, Tantawi H, Al-Moslih M, Al-Janabi N, Mahmud MI, Al-Bana A, Habib H, Al-Munthri H, Al-Janabi S, Al-Jawahry K, Yonan M, Hassan F, Simpson DI, 1981. Congo/Crimean haemorrhagic fever in Iraq. Bull World Health Organ 59 :85–90.

    • Search Google Scholar
    • Export Citation
  • 8

    Burney MI, Ghafoor A, Saleen M, Webb PA, Casals J, 1980. Nosocomial outbreak of viral hemorrhagic fever caused by Crimean hemorrhagic fever-Congo virus in Pakistan, January 1976. Am J Trop Med Hyg 29 :941–947.

    • Search Google Scholar
    • Export Citation
  • 9

    Bosan AH, Kakar F, Dil AS, Asghar H, Zaidi S, 2000. Crimean-Congo hemorrhagic fever (CCHF) in Pakistan. Dis Surveillance 2 :4–5.

  • 10

    el-Azazy OM, Scrimgeour EM, 1997. Crimean-Congo haemorrhagic fever virus infection in the western province of Saudi Arabia. Trans R Soc Trop Med Hyg 91 :275–278.

    • Search Google Scholar
    • Export Citation
  • 11

    Burt FJ, Swanepoel R, Shieh WJ, Smith JF, Leman PA, Greer PW, Coffield LM, Rollin PE, Ksiazek TG, Peters CJ, Zaki SR, 1997. Immunohistochemical and in situ localization of Crimean-Congo hemorrhagic fever (CCHF) virus in human tissues and implications for CCHF pathogenesis. Arch Pathol Lab Med 121 :839–846.

    • Search Google Scholar
    • Export Citation
  • 12

    van Eeden PJ, Joubert JR, van de Wal BW, King JB, de Kock A, Groenewald JH, 1985. A nosocomial outbreak of Crimean-Congo haemorrhagic fever at Tygerberg Hospital. Part I. Clinical features. S Afr Med J 68 :711–717.

    • Search Google Scholar
    • Export Citation
  • 13

    Swanepoel R, Shepherd AJ, Leman PA, Shepherd SP, McGillivray GM, Erasmus MJ, Searle LA, Gill DE, 1987. Epidemiologic and clinical features of Crimean-Congo hemorrhagic fever in southern Africa. Am J Trop Med Hyg 36 :120–132.

    • Search Google Scholar
    • Export Citation
  • 14

    Khan AS, Maupin GO, Rollin PE, Noor AM, Shurie HH, Shalabi AG, Wasef S, Haddad YM, Sadek R, Ijaz K, Peters CJ, Ksiazek TG, 1997. An outbreak of Crimean-Congo hemorrhagic fever in the United Arab Emirates, 1994–1995. Am J Trop Med Hyg 57 :519–525.

    • Search Google Scholar
    • Export Citation
  • 15

    Altaf A, Luby S, Ahmed AJ, Zaidi N, Khan AJ, Mirza S, Mc-Cormick J, Fisher-Hoch S, 1998. Outbreak of Crimean-Congo haemorrhagic fever in Quetta, Pakistan: contact tracing and risk assessment. Trop Med Int Health 3 :878–882.

    • Search Google Scholar
    • Export Citation
  • 16

    Athar MN, Baqai HZ, Ahmad M, Khalid MA, Bashir N, Ahmad AM, Balouch AH, Bashir K, 2003. Short report: Crimean-Congo hemorrhagic fever outbreak in Rawalpindi, Pakistan, February 2002. Am J Trop Med Hyg 69 :284–287.

    • Search Google Scholar
    • Export Citation
  • 17

    Shepherd AJ, Swanepoel R, Leman PA, 1989. Antibody response in Crimean-Congo hemorrhagic fever. Rev Infect Dis 11 (Suppl 4): S801–S806.

    • Search Google Scholar
    • Export Citation
  • 18

    Fisher-Hoch SP, McCormick JB, Swanepoel R, Van Middlekoop A, Harvey S, Kustner HG, 1992. Risk of human infections with Crimean-Congo hemorrhagic fever virus in a South African rural community. Am J Trop Med Hyg 47 :337–345.

    • Search Google Scholar
    • Export Citation
  • 19

    CDC, 1988. Management of patients with suspected Viral Hemorrhagic Fever. MMWR Morb Mortal Wkly Rep 37 :1–16.

  • 20

    Baron RC, McCormick JB, Zubeir OA, 1983. Ebola virus disease in southern Sudan: hospital dissemination and intrafamilial spread. Bull World Health Organ 61 :997–1003.

    • Search Google Scholar
    • Export Citation
  • 21

    CDC, 1995. Notice to Readers Update: Management of Patients with Suspected Viral Hemorrhagic Fever–United States. MMWR Morb Motal Wkly Rep 44 :475–479.

    • Search Google Scholar
    • Export Citation
  • 22

    CDC, 1990. Update: Filovirus infections among persons with occupational exposure to nonhuman primates. MMWR Morb Mortal Wkly Rep 39 :266–267.

    • Search Google Scholar
    • Export Citation
  • 23

    Dalgard DW, Hardy RJ, Pearson SL, Pucak GJ, Quander RV, Zack PM, Peters CJ, Jahrling PB, 1992. Combined simian hemorrhagic fever and Ebola virus infection in cynomolgus monkeys. Lab Anim Sci 42 :152–157.

    • Search Google Scholar
    • Export Citation
  • 24

    Joubert JR, King JB, Rossouw DJ, Cooper R, 1985. A nosocomial outbreak of Crimean-Congo haemorrhagic fever at Tygerberg Hospital: Part III. Clinical pathology and pathogenesis. S Afr Med J 68 :722–728.

    • Search Google Scholar
    • Export Citation
  • 25

    van de Wal BW, Joubert JR, van Eeden PJ, King JB, 1985. A nosocomial outbreak of Crimean-Congo haemorrhagic fever at Tygerberg Hospital. Part IV. Preventive and prophylactic measures. S Afr Med J 68 :729–732.

    • Search Google Scholar
    • Export Citation
  • 26

    Fisher-Hoch SP, Price ME, Craven RB, Price FM, Forthall DN, Sasso DR, Scott SM, McCormick JB, 1985. Safe intensive-care management of a severe case of Lassa fever with simple barrier nursing techniques. Lancet 2 :1227–1229.

    • Search Google Scholar
    • Export Citation
 
 
 

 

 
 
 

 

 

 

 

 

 

CRIMEAN-CONGO HEMORRHAGIC FEVER OUTBREAK IN RAWALPINDI, PAKISTAN, FEBRUARY 2002: CONTACT TRACING AND RISK ASSESSMENT

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  • 1 Department of Internal Medicine, Mercy Catholic Medical Center, Darby, Pennsylvania; Department of Medicine, and Department of Pathology, Holy Family Hospital, Rawalpindi Medical College, Rawalpindi, Pakistan; Department of Community Health Sciences, The Aga Khan University, Karachi, Pakistan

A 25-year-old woman, later identified as index case of Crimean-Congo hemorrhagic fever (CCHF), presented to Holy Family Hospital in Rawalpindi, Pakistan with fever and generalized coagulopathy. A retrospective contact tracing was conducted to explore the modes of exposure possibly associated with transmission of CCHF infection among contacts. We traced 32 contacts of the index case and 158 contacts of secondary cases and tested them for IgG and IgM antibodies against CCHF virus by an enzyme-linked immunosorbent assay technique. According to the type of exposure, contacts were divided into five subsets: percutaneous contact with blood, blood contact to unbroken skin, cutaneous contact to non-sanguineous body fluids, physical contact with patients without body fluids contact, and close proximity without touching. Two out of four contacts who reported percutaneous exposure tested positive for antibodies to CCHF virus. We conclude that simple barrier methods and care in provision of CCHF cases may prevent transmission of this infection.

INTRODUCTION

Crimean-Congo hemorrhagic fever (CCHF) virus is known to be transmitted by Hyalomma ticks.1 The first case of CCHF was described in the former Soviet Union in 1944.2,3 Since then outbreaks have been reported from the USSR, Bulgaria, Saudi Arabia,4 the United Arab Emirates,5 Kuwait,6 Pakistan, and Iraq.7

Crimean-Congo hemorrhagic fever is endemic in Pakistan. The first case in this country occurred in 1976.8 Nosocomial outbreaks have been reported in recent years in Pakistan,9 Iraq,10 Dubai,11 and South Africa.12,13 Mortality is reported to be high (from 15% to 100%).10,11,14 It has been shown that the duration of contact determines the transmissibility of CCHF virus among humans; however, epidemiologic studies also indicate that infection is not readily transmitted via the aerial route.15

We conducted a retrospective contact tracing to explore modes of exposure possibly associated with transmission of CCHF virus infection among contacts.

CASE SUMMARY

A 25-year-old woman was referred to Holy Family Hospital in Rawalpindi, Pakistan with a one-week history of high-grade fever, rigors, myalgias, and generalized coagulopathy.16 Laboratory studies were consistent with disseminated intra-vascular coagulation (DIC). The patient identified as the index case of CCHF died 36 hours after presentation. No serum sample was saved for retrospective diagnosis because there was no suspicion of CCHF virus infection.

Five days after the death of the index case, one of the female interns involved in her care developed fever, chills, vomiting, and abdominal pain. A coagulation profile, the results of which was initially normal, showed marked deterioration on day 4 of the illness, consistent with DIC. Unfortunately, the intern died on day 8 of her illness. Antibodies (IgM and IgG) were detected in the serum sample taken on day 6 by an enzyme-linked immunoassay (ELISA) technique.17 Virus was also isolated from the same serum sample by a reverse transcriptase–polymerase chain reaction (RT-PCR) assay.

A male intern also managed the index case. He developed flu-like symptoms four days after contact, followed by high-grade fever (101.6°F), epistaxis, and several episodes of gum bleeds. Suspecting CCHF, anti-viral therapy with oral ribavirin was prescribed and the patient was effectively isolated at home. Diagnosis of CCHF was later confirmed by ELISA.

The exposed included the secondary cases, the families of all three cases, and all health care workers (HCWs) coming in contact with the index and secondary cases. The number of contacts was high (n = 190). To explore the possible modes of CCHF transmission, contacts were divided into five categories15: A) percutaneous contact with blood (needle pricks, blood contact to broken skin/mucosa), B) blood contact to unbroken skin, C) cutaneous contact to non-sanguineous body fluids (e.g., saliva, sweat, vomitus, urine, and feces), D) physical contact with patients without body fluids contact, and E) close proximity to the patient without touching (Table 1).

Samples were collected from the high-risk contacts (category A, B, and C) and were tested with anti-human immunoglobulin antibodies for the presence of IgG and IgM antibodies against CCHF virus by ELISA. The diagnosis was confirmed by isolating the virus using an RT-PCR assay.

RESULTS

Contact investigation of the index case.

Eight relatives of the index case reported contact with blood and extensive physical contact with the patient (category B). None of them developed any symptom(s) or signs of CCHF. Their serum samples were all negative for antibodies against CCHF virus. Twelve HCWs provided care to the index case. Secondary case 1 had appreciable contact with the respiratory secretions and blood of the index case while changing intravenous infusions and performing gastric lavage. Later, she also gave mouth-to-mouth respiration to the index case. She may have acquired the virus either by blood spilling on her hand or by respiratory secretions coming in contact with her eyes or buccal mucosa. Because of the nature of her contact she was placed in category A.

Secondary case 2 reported appreciable exposure to respiratory secretions of the index case while performing gastric lavage, during which the index case was coughing in his face. He wore latex gloves, but no face shields were used. He was also placed in category A.

Five HCW, who reported contact with vomitus, respiratory secretions, and oozing serous fluid from the puncture site (category C) and another five, which had extensive physical contact with the index case (category D) did not report any symptoms of CCHF.

Contact investigation of the secondary case 1.

The sister of secondary case 1 was exposed to blood when cleaning hematemesis and changing vaginal pads. However, she reported no percutaneous contact (category B). Two other family members had extensive physical contact but no exposure to her secretions (category D). The sister of the intern tested negative for antibodies to CCHF virus. The female intern had 125 HCWs as contacts. Among them, two reported needle prick injury (category A), and 25 reported blood contact (category B). Antibodies to CCHF virus were not detected in their serum. Seventeen HCWs had cutaneous contact with non-sanguineous body fluids (vomitus and respiratory secretions-category C). Twenty-five HCWs were placed in category D and 56 in were placed in category E. None of them developed or reported any features of CCHF.

Contact investigation of the secondary case 2.

The mother of secondary case 2 had blood contact on unbroken skin (category B). Three other family members had close physical contact but no contact with his body fluids (category D). None of the contacts developed any features suggestive of CCHF, or tested positive for antibodies to CCHF virus by ELISA. Nine HCWs were placed in category D and eight were placed in category E. They all remained asymptomatic.

DISCUSSION

Crimean-Congo hemorrhagic fever is reported to be highly contagious with mortality of approximately 15–100%.10,11,14 The recommended safety measures include barrier nursing, isolation of the patient, and gloves, gowns, face shields, and goggles with side shields when contacting the patient or the soiled environment. There is insufficient data to support transmission by an airborne mechanism.18–20 Airborne transmission in animals was noted in some studies and was used to justify the stringent precautionary methods.21–23 Concerns have also been raised about two nosocomial cases that occurred in South Africa without any documented evidence of direct exposure to infectious material.24,25 However, all other evidence ruled out airborne transmission. In our experience, none of the contacts developed the disease after sharing the same environment as the index or the secondary cases. Of the 190 listed contacts, 2 (1.05%) developed the disease; both were the contacts of index case.

Percutaneous exposure remained the highest risk of transmission.20 An attack rate of 50% was seen in contacts that had a percutaneous or equivalent exposure (category A) (Table 2). However, due to the fact that the number of contacts who had category A exposure was small (four), we recommend interpreting these findings with caution. The percutaneous exposure that occurred from the index case to secondary case 1 was either in the form of saliva or respiratory secretions coming in contact with buccal mucosa or blood contact with broken skin not evident by the naked eye. The risk of cutaneous transmission through unnoticed skin breach necessitates cautious handling of blood and blood products. The male intern noted appreciable contact of respiratory secretions of index case with his eyes and face. Recommendations demand use of face shields or surgical masks, and wearing eye protection by persons coming within approximately three feet of the patient to prevent contact with blood, other body fluids, secretions, or excretions.21

We conclude that the health care professional caring for CCHF patients should take all possible safety measures to avoid contact with blood or secretions, and simple barrier nursing effectively prevents the disease, as has been seen in Lassa fever cases.26 It also appears that CCHF is not spread by air. However, further studies are needed to elaborate the specific routes of transmission of the disease.

Experts from developed countries recommend expensive approach such as high-efficiency particulate air respirators for HCWs caring for the CCHF patients and negative pressure isolation rooms.26 Such approaches are costly and not feasible for a third-world country such as Pakistan.

Table 1

Categorization of contacts

Index caseSecondary case 1Secondary case 2
Categories*Family contactsHospital contactsFamily contactsHospital contactsFamily contactsHospital contacts
* A = percutaneous contact with blood, and contact of blood to broken skin or mucosa; B = cutaneous contact with blood; C = cutaneous contact with nonsanguinous body fluids; D = physical contact with patients without body fluids contact; E = close proximity without touching the patient.
A020200
B8012510
C0501700
D6522539
E6005698
Table 2

Calculation of attack rate

Categories*Contacts exposedAttack rate
* A = Percutaneous contact with blood, and contact of blood to broken skin or mucosa; B = cutaneous contact with blood; C = cutaneous contact with nonsanguinous body fluids; D = physical contact with patients without body fluids contact; E = close proximity without touching the patient.
A42/450%
B350/350%
C220/220%
D500/500%
E790/790%

Authors’ addresses: Muhammad Nauman Athar, Department of Internal Medicine, Mercy Catholic Medical Center, 1500 Lansdowne Avenue, Darby, PA 19023, Telephone: 610-237-4553. Mohammad Ali Khalid, Naghman Bashir, Haider Zaigum Baqai, Masood Ahmad, and Kaukab Bashir, Medical Unit II, Department of Medicine, Holy Family Hospital and Rawalpindi Medical College, Satellite Town, Rawalpindi, Pakistan, Telephone: 92-51-929-0321-27 Extension 272-277, Fax: 92-51-929-0518. Ahsan Maqbool Ahmad, Department of Community Health Sciences, Second Floor, Ibn-e-Ridwan Building, The Aga Khan University, Stadium Road, Karachi, Pakistan, Telephone: 92-(21-4859-4923. Fax: 92-21-493-4294. Abbas Hayat Balouch, Department of Pathology, Holy Family Hospital and Rawalpindi Medical College, Satellite Town, Rawalpindi, Pakistan, Telephone: 92-51-929-0321-27, Fax: 92-51-929-0518.

Acknowledgments: We are grateful to Samina Satti and Raja Mohammad Babar Akram (Department of Medicine, Holy Family Hospital, Rawalpindi, Pakistan) for reviewing the manuscript, and to Hamayun Asghar, Athar Saeed Dil (Public Health Division, National Institute of Health, Islamabad, Pakistan) and the staff of the National Institute of Virology (Johannesburg, South Africa) for invaluable technical assistance. We are proud to be associated with Farzana Altaf (House Physician, Holy Family Hospital), whose energy in improving standards were in the best traditions of our profession.

REFERENCES

  • 1

    Hoogstraal H, 1979. The epidemiology of tick-borne Crimean-Congo hemorrhagic fever in Asia, Europe, and Africa. J Med Entemol 15 :307–417.

    • Search Google Scholar
    • Export Citation
  • 2

    Leshchinskaya EV, 1965. Crimean hemorrhagic fever. Trudy Inst Polio Virus Entsef Akad Med Nauk SSSR 7 :226–236.

  • 3

    Casals J, Henderson BE, Hoogstraal H, Johnson KM, Shelokov A, 1970. A review of Soviet viral hemorrhagic fevers, 1969. J Infect Dis 122 :437–453.

    • Search Google Scholar
    • Export Citation
  • 4

    Scrimgeour EM, 1995. Communicable diseases in Saudia Arabia; an epidemiological review. Trop Dis Bull 92 :R79–R95.

  • 5

    Suleiman MN, Muscat-Baron JM, Harries JR, Satti AG, Platt GS, Bowen ET, Simpson DI, 1980. Congo/Crimean haemorrhagic fever in Dubai. An outbreak at the Rashid Hospital. Lancet 2 :939–941.

    • Search Google Scholar
    • Export Citation
  • 6

    Al-Nakib W, Lloyd G, El-Mekki A, Platt G, Beeson A, Southee T, 1984. Preliminary report on arbovirus-antibody prevalence among patients in Kuwait: evidence of Congo-Crimean virus infection. Trans R Soc Trop Med Hyg 78 :474–476.

    • Search Google Scholar
    • Export Citation
  • 7

    Al-Tikriti SK, Al-Ani F, Jurji FJ, Tantawi H, Al-Moslih M, Al-Janabi N, Mahmud MI, Al-Bana A, Habib H, Al-Munthri H, Al-Janabi S, Al-Jawahry K, Yonan M, Hassan F, Simpson DI, 1981. Congo/Crimean haemorrhagic fever in Iraq. Bull World Health Organ 59 :85–90.

    • Search Google Scholar
    • Export Citation
  • 8

    Burney MI, Ghafoor A, Saleen M, Webb PA, Casals J, 1980. Nosocomial outbreak of viral hemorrhagic fever caused by Crimean hemorrhagic fever-Congo virus in Pakistan, January 1976. Am J Trop Med Hyg 29 :941–947.

    • Search Google Scholar
    • Export Citation
  • 9

    Bosan AH, Kakar F, Dil AS, Asghar H, Zaidi S, 2000. Crimean-Congo hemorrhagic fever (CCHF) in Pakistan. Dis Surveillance 2 :4–5.

  • 10

    el-Azazy OM, Scrimgeour EM, 1997. Crimean-Congo haemorrhagic fever virus infection in the western province of Saudi Arabia. Trans R Soc Trop Med Hyg 91 :275–278.

    • Search Google Scholar
    • Export Citation
  • 11

    Burt FJ, Swanepoel R, Shieh WJ, Smith JF, Leman PA, Greer PW, Coffield LM, Rollin PE, Ksiazek TG, Peters CJ, Zaki SR, 1997. Immunohistochemical and in situ localization of Crimean-Congo hemorrhagic fever (CCHF) virus in human tissues and implications for CCHF pathogenesis. Arch Pathol Lab Med 121 :839–846.

    • Search Google Scholar
    • Export Citation
  • 12

    van Eeden PJ, Joubert JR, van de Wal BW, King JB, de Kock A, Groenewald JH, 1985. A nosocomial outbreak of Crimean-Congo haemorrhagic fever at Tygerberg Hospital. Part I. Clinical features. S Afr Med J 68 :711–717.

    • Search Google Scholar
    • Export Citation
  • 13

    Swanepoel R, Shepherd AJ, Leman PA, Shepherd SP, McGillivray GM, Erasmus MJ, Searle LA, Gill DE, 1987. Epidemiologic and clinical features of Crimean-Congo hemorrhagic fever in southern Africa. Am J Trop Med Hyg 36 :120–132.

    • Search Google Scholar
    • Export Citation
  • 14

    Khan AS, Maupin GO, Rollin PE, Noor AM, Shurie HH, Shalabi AG, Wasef S, Haddad YM, Sadek R, Ijaz K, Peters CJ, Ksiazek TG, 1997. An outbreak of Crimean-Congo hemorrhagic fever in the United Arab Emirates, 1994–1995. Am J Trop Med Hyg 57 :519–525.

    • Search Google Scholar
    • Export Citation
  • 15

    Altaf A, Luby S, Ahmed AJ, Zaidi N, Khan AJ, Mirza S, Mc-Cormick J, Fisher-Hoch S, 1998. Outbreak of Crimean-Congo haemorrhagic fever in Quetta, Pakistan: contact tracing and risk assessment. Trop Med Int Health 3 :878–882.

    • Search Google Scholar
    • Export Citation
  • 16

    Athar MN, Baqai HZ, Ahmad M, Khalid MA, Bashir N, Ahmad AM, Balouch AH, Bashir K, 2003. Short report: Crimean-Congo hemorrhagic fever outbreak in Rawalpindi, Pakistan, February 2002. Am J Trop Med Hyg 69 :284–287.

    • Search Google Scholar
    • Export Citation
  • 17

    Shepherd AJ, Swanepoel R, Leman PA, 1989. Antibody response in Crimean-Congo hemorrhagic fever. Rev Infect Dis 11 (Suppl 4): S801–S806.

    • Search Google Scholar
    • Export Citation
  • 18

    Fisher-Hoch SP, McCormick JB, Swanepoel R, Van Middlekoop A, Harvey S, Kustner HG, 1992. Risk of human infections with Crimean-Congo hemorrhagic fever virus in a South African rural community. Am J Trop Med Hyg 47 :337–345.

    • Search Google Scholar
    • Export Citation
  • 19

    CDC, 1988. Management of patients with suspected Viral Hemorrhagic Fever. MMWR Morb Mortal Wkly Rep 37 :1–16.

  • 20

    Baron RC, McCormick JB, Zubeir OA, 1983. Ebola virus disease in southern Sudan: hospital dissemination and intrafamilial spread. Bull World Health Organ 61 :997–1003.

    • Search Google Scholar
    • Export Citation
  • 21

    CDC, 1995. Notice to Readers Update: Management of Patients with Suspected Viral Hemorrhagic Fever–United States. MMWR Morb Motal Wkly Rep 44 :475–479.

    • Search Google Scholar
    • Export Citation
  • 22

    CDC, 1990. Update: Filovirus infections among persons with occupational exposure to nonhuman primates. MMWR Morb Mortal Wkly Rep 39 :266–267.

    • Search Google Scholar
    • Export Citation
  • 23

    Dalgard DW, Hardy RJ, Pearson SL, Pucak GJ, Quander RV, Zack PM, Peters CJ, Jahrling PB, 1992. Combined simian hemorrhagic fever and Ebola virus infection in cynomolgus monkeys. Lab Anim Sci 42 :152–157.

    • Search Google Scholar
    • Export Citation
  • 24

    Joubert JR, King JB, Rossouw DJ, Cooper R, 1985. A nosocomial outbreak of Crimean-Congo haemorrhagic fever at Tygerberg Hospital: Part III. Clinical pathology and pathogenesis. S Afr Med J 68 :722–728.

    • Search Google Scholar
    • Export Citation
  • 25

    van de Wal BW, Joubert JR, van Eeden PJ, King JB, 1985. A nosocomial outbreak of Crimean-Congo haemorrhagic fever at Tygerberg Hospital. Part IV. Preventive and prophylactic measures. S Afr Med J 68 :729–732.

    • Search Google Scholar
    • Export Citation
  • 26

    Fisher-Hoch SP, Price ME, Craven RB, Price FM, Forthall DN, Sasso DR, Scott SM, McCormick JB, 1985. Safe intensive-care management of a severe case of Lassa fever with simple barrier nursing techniques. Lancet 2 :1227–1229.

    • Search Google Scholar
    • Export Citation

Author Notes

Reprint requests: Muhammad Nauman Athar, 151 South Bishop Avenue, Apartment #K-12, Secane, PA 19018, Telephone/Fax: 610-394-6331, E-mail: drnaumanathar@yahoo.com.
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