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Table of Contents
Year : 2019  |  Volume : 56  |  Issue : 3  |  Page : 276-279

Crimean-Congo hemorrhagic fever virus Asia 2 genotype in Qeshm Island, southern Iran: A case report

1 Department of Arboviruses and Viral Hemorrhagic Fevers (National Reference Laboratory), Pasteur Institute of Iran, Tehran, Iran
2 Research Center for Emerging and Re-emerging Infectious Disease; Department of Arboviruses and Viral Hemorrhagic Fevers (National Reference Laboratory), Pasteur Institute of Iran, Tehran, Iran

Date of Submission15-May-2018
Date of Acceptance14-Dec-2018
Date of Web Publication09-Jul-2020

Correspondence Address:
Dr Mostafa Salehi-Vaziri
Department of Arboviruses and Viral Hemorrhagic Fevers (National Reference Laboratory), Pasteur Institute of Iran, No. 69, Pasteur Ave, Tehran, 1316943551
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-9062.289389

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Keywords: Asia 2; Crimean-Congo hemorrhagic fever; Eid-al-Adha; Iran; Qeshm Island

How to cite this article:
Fazlalipour M, Baniasadi V, Pouriayevali MH, Jalali T, Mohammadi T, Azad-Manjiri S, Azizizadeh S, Hosseini M, Fereydouni Z, Tavakoli M, Ghalejoogh M, Khakifirouz S, Salehi-Vaziri M. Crimean-Congo hemorrhagic fever virus Asia 2 genotype in Qeshm Island, southern Iran: A case report. J Vector Borne Dis 2019;56:276-9

How to cite this URL:
Fazlalipour M, Baniasadi V, Pouriayevali MH, Jalali T, Mohammadi T, Azad-Manjiri S, Azizizadeh S, Hosseini M, Fereydouni Z, Tavakoli M, Ghalejoogh M, Khakifirouz S, Salehi-Vaziri M. Crimean-Congo hemorrhagic fever virus Asia 2 genotype in Qeshm Island, southern Iran: A case report. J Vector Borne Dis [serial online] 2019 [cited 2023 Mar 31];56:276-9. Available from: http://www.jvbd.org//text.asp?2019/56/3/276/289389

Crimean-Congo hemorrhagic fever virus (CCHFV) is an RNA virus classified in genus Orthonairovirus of family Nairoviridae within the order Bunyavirales (International Committee on Taxonomy of Viruses 2016). The CCHF was first described in Crimea in 1944 and since then the disease has been reported from more than 30 countries in Africa, Europe, Asia, and the Middle-East. Like other Nairoviruses CCHFV is a tick-borne virus and Ixodid ticks (particularly of genus Hyalomma) play a crucial role in the maintenance of the virus in nature. During blood feeding, infected ticks can transmit the virus to various vertebrate hosts including wild/domestic animals and humans. Humans can also acquire the virus by close contact with blood or tissues from viraemic animals and other patients[1].

After a short incubation period of 1 to 7 days, flulike syndrome suddenly occurs and then the hemorrhagic phase develops. The case fatality rate of CCHF varies from 5 to 50%; however, in some outbreaks, significant mortality rate of 73% was also recorded[1],[2],[3].

In Iran, one of the CCHF endemic countries in the Middle-East, the main route of CCHFV transmission is direct contact with the blood of tissues from viraemic livestock[4]. Phylogenetically, CCHFV has been categorized into 7 different genotypes which have been known as Asia 1-2, Africa 1–3 and Europe1-2 because of their specific geographical distribution[1]. Although Asia 1 is the most prevalent genotype in Iran, Asia 2, Europe 1 and Europe 2 have been sporadically reported from the country[1],[5],[6].

This case report describes an Asia 2 CCHFV infection following livestock slaughtering during Eid-al-Adha (an Islamic festival) in Qeshm Island which is located in the Persian Gulf, near Bandar Abbas port.

Case report

A 35-yr-old man was admitted to the Payambar Azam Hospital (Qeshm, Hormozgan Province), on 13 September 2017, with a five-day history of flu-like symptoms including fever, abdominal pain, muscle pain, vomiting, and nausea. No hemorrhagic presentations were observed and other physical examinations were unremarkable. The patient was a government employee and lived in a rural area of Qeshm Island.

Seven days before the onset of symptoms (on 6 September 2017; the day of Eid-al-Adha), he sacrificed three sheep imported from Minab city to Qeshm Island. It is noteworthy that during slaughtering he had cut his finger by the same knife that was being used.

Laboratory investigations on the first sample (on 13 September 2017) revealed thrombocytopenia (platelet = 110,000/μl), leukopenia (white blood cells = 2700/μl), neutropenia, low mean corpuscular volume (77.57 fl), and low mean corpuscular hemoglobin (25.05 pg). Other haematology parameters were in the normal range. The CCHF was suspected based on epidemiological background, clinical picture, and laboratory findings. According to the national guidelines for CCHF surveillance and control, all the CCHF probable cases have to be subjected to ribavirin treatment and supportive therapy. Therefore, ribavirin therapy was prescribed based on the dosage recommended by the World Health Organization (30 mg/kg as an initial loading dose, then 15 mg/kg every 6 h for 4 days, and then 7.5 mg/kg every 8 h for 6 days)[7].

On the second day of admission (14 September 2017), platelet count dropped to 95,000/μl and few giant platelets were seen in the peripheral blood smear. On the 5th day of admission platelet count increased to 203,000/μl, and elevated liver enzymes (aspartate transaminase = 71, alanine aminotransferase = 155 mg/dl) and prolonged prothrombin time (PT) were observed. Two days later, platelet count increased to 320,000/ μl, PT became normal and levels of liver enzymes began to decrease (aspartate transaminase = 42, alanine aminotransferase = 121 mg/dl). Finally, the patient recovered and was discharged from the hospital on the 7th day of admission.

For confirmation of CCHF, a serum sample was taken from the patient and sent to the Department of Arboviruses and Viral Hemorrhagic fevers of Pasteur Institute of Iran (National Reference Lab), Tehran. The CCHFV RNA and anti-CCHFV IgM antibody were detected by the use of reverse transcriptase-polymerase chain reaction (RT-PCR) and IgM Capture Enzyme-Linked Immunosorbent Assay (MAC-ELISA) as described previously[8]. The RT-PCR test was carried out using the One-Step RT-PCR Kit (QIAgen GmbH, Hilden, Germany) and F2/R3 primers (F2 5′-TGGACACCTTCACAAACTC-3′ and R3 5′-GACAATTCCCTACACC-3′). The PCR product was sequenced by ABI 3500 Genetic Analyzer (Applied Bio-systems, USA). The raw data of sequencing were trimmed by the CLC Main Workbench 5.5 package (CLC bio, Denmark), and then verified by BLAST (http://blast.ncbi.nlm. nih.gov/Blast.cgi). The obtained sequence (Iran-5995) was deposited in the GenBank under accession number MG456911. Phylogenetic analysis was accomplished by MEGA-5 software, using the Clustal W tool for multiple sequence alignment and the maximum likelihood method (with 10,000 Bootstrap replicates) to construct the phylogenetic tree[5]. As can be seen in [Figure 1] the isolate (Iran- 5995) clustered within the Asia 2 genotype.
Figure 1: Phylogenetic tree (generated by MEGA-5 software using the Clustal W tool for multiple sequence alignment and the maximum likelihood method with 10,000 Bootstrap replicates) representing the close relation of the isolate Iran-5995 to the strains from Asia 2 genotype.

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For MAC-ELISA, the ELISA plate was coated with Goat anti-Human IgM antibody diluted in 1× PBS (phosphate-buffered saline) and incubated. The serum sample diluted in PBSTM (PBS with 0.05% Tween and 3% skimmed milk) was added to the plate and incubated. Then, CCHFV inactivated antigen was added to the plate and incubated. Subsequently, hyperimmune mouse anti-CCHFV ascitic fluid diluted in PBSTM was added and incubated, followed by the addition of horseradish peroxidase (HRP) conjugated secondary antibody and incubation. Eventually, hydrogen peroxide (H2O2) and 3, 3’, 5, 5’ tetramethylbenzidine (TMB) were added and the plate was incubated at ambient temperature for 15 min followed by addition of 4 N H2SO4 to stop the reaction and the optical density (OD) measurement.

This is the first report of CCHF from Qeshm Island in the Persian Gulf, near Bandar Abbas port on the southern coast of Iran (due to traditional slaughtering of livestock) during the Eid-al-Adha festival. Eid-al-Adha is one of the most important religious ceremonies in Islam during which livestock sacrifices are performed by Muslims. Zoonotic transmission of CCHFV as a consequence of slaughtering of animal and subsequent manipulation of carcasses increases during this ceremony[9]. Recently, there has been an increase in the incidence of CCHF in Pakistan during the Eid-al-Adha[10],[11]. In contrast, this trend has not been observed in Iran which indicates the effectiveness of measures taken by the health authorities to carry out standard slaughtering of the animal during this celebration. However, traditional slaughtering without using proper personal protective equipment (PPE) is still practiced, especially in small towns and rural areas[9].

Despite the effectiveness of preventive measures in Iran, Eid-al-Adha remains a serious public health concern due to the following reasons: (a) The timing of Eid-al- Adha drifts about 11 days earlier each year. Therefore, in the next 10-15 yrs this ceremony will fall in summer and spring[12] when ticks are more active and thus livestock are more likely to be infected with CCHFV; and (b) During this festival, the rate of uncontrolled livestock movements within the country and from eastern neighboring countries increases dramatically[9]. This can facilitate the dissemination of the virus and also the introduction of new stains to new regions.

In this study, we found an isolate belonging to Asia 2 genotype, while the most common circulating genotype in Iran is Asia 1 and there is only one study[13] reporting Asia 2 genotype in two Iranian patients from Sistan and Baluchistan province in 2011 and 2012, respectively[13]. The Asia 2 genotype has been reported mainly from China and central Asia[14]. However, sporadic cases have been reported in Pakistan and the United Arab Emirates. Although it is speculated that CCHFV genotypes have a particular geographic distribution, the occurrence of geographically distant but genetically related isolates indicate the spread of the virus through animal trade. Considering the fragmented nature of the CCHFV genome, the introduction of new stains to an endemic area could lead to the creation of reassortant strains with new phenotypes[15],[16].

The patient was successfully treated with ribavirin. Ribavirin has been shown to have an inhibitory effect in CCHFV replication; however, its clinical efficacy is a matter of debate. The results from two systematic reviews published in 2010 and 2011 indicated no remarkable advantage of ribavirin treatment[17],[18]. However, in these reviews, the low quality of the analyzed data and a high risk of bias were highlighted by the authors suggesting the inadequacy of evidences and the need for further studies[17],[18]. Though, recent data support the effectiveness of ribavirin especially as an early treatment[19],[20] and based on severity scoring index[21].

In conclusion, this report indicates a potential risk of CCHFV transmission due to livestock during Eid-al- Adha in Iran and also the introduction of new stains to the country as a result of uncontrolled animal movement during this festival. Necessary health approaches to mitigate the risk of CCHF during Eid-al-Adha requires: (a) Control of CCHFV infection in animal hosts by the use of acaricides and a two-week period of quarantine before slaughtering; (b) Control of animal movement; and (c) Decreasing the risk of infection in people by education and raising awareness.

Ethical statement

The present study was performed according to the Declaration of Helsinki and relevant national health regulations. The study related protocols were carried out according to the national program for CCHF surveillance and control in Iran.

Conflict of interest: None

  Acknowledgements Top

This work was funded by the Centre for Diseases Control and Prevention of Iran as part of the national program for CCHF surveillance and control in Iran.

  References Top

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  [Figure 1]

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