CrimeanCongo Haemorrhagic Fever DIAGNOSIS Herv Zeller National Reference

Crimean-Congo Haemorrhagic Fever DIAGNOSIS Hervé Zeller National Reference Center - WHO Collaborating Centre for Arboviruses and Viral Haemorrhagic Fevers, Institut Pasteur, Lyon

Flaviviridae (dengue, yellow fever, Groupe TBE) Viral Haemorrhagic Fevers

Flaviviridae (dengue, yellow fever, Groupe TBE) Viral Haemorrhagic Fevers Arenaviridae (Lassa, Junin, Machupo, Guanarito)

Flaviviridae (dengue, yellow fever, Groupe TBE) Viral Haemorrhagic Fevers Arenaviridae (Lassa, Junin, Machupo, Guanarito) Filoviridae (Ebola, Marburg)

Flaviviridae (dengue, yellow fever, Groupe TBE) Viral Haemorrhagic Fevers Arenaviridae (Lassa, Junin, Machupo, Guanarito) Envelopped RNA viruses Filoviridae (Ebola, Marburg) Bunyaviridae (CCHF, RVF, Hantaviruses)

Family Genus VIRUS DISTRIBUTION Flaviviridae Flavivirus Yellow Fever Dengue 1, 2, 3, 4. Africa South America Tropical areas Omsk HF Alkhurma Russia Saudi Arabia Kyasanur Forest HF India Phlebovirus Rift Valley Fever Africa, Saudi Arabia Nairovirus Crimean-Congo HF Africa, Eurasia Hantavirus Hantan Dobrava Puumala Eurasia Sin Nombre, Andes Americas Bunyaviridae

Hemorrhages are inconstant : Emerging part of the iceberg …Most frequently asymptomatic infections +++

Biosafety Issues Related to Haemorrhagic Fever Viruses • Criteria for classification – Disease severity – Transmissibility to laboratory workers – Availability of treatment – Availability of vaccine • Classification BSL 1 to BSL 4

CCHF VIABILITY SENSITIVITY TO DESINFECTANTS: sodium hypochlorite 2%, glutaraldehyde 2%, formaldehyde SENSITIVE TO DESSICATION INACTIVATION : IRRADIATION UV TEMPERATURE : 1 hour 60°C not complete inactivation beta propiolactone 4°C not complete inactivation

Nairovirus structure G 1 N G 2 M S L L 10 nm

CCHF Nairovirus genome _______________________ Segment Nucleotides Amino acids Protein _______________________ S 1659 -1712 M 4888 442 -482 N 1551 G 1 G 2 NSm? L 12255 4036 L? _______________________

VHF SUSPECT CASE

VHF SUSPECT CASE Malaria – Hepatitis – Typhoidis – Toxicosis Septicemia – Leptospirosis Rickettsiosis…

VHF SUSPECT CASE Malaria – Hepatitis – Typhoidis – Toxicosis Septicemia – Leptospirosis Rickettsiosis… Epidemiological data, risk evaluation biological analysis, differential diagnostic

VHF SUSPECT CASE Malaria – Hepatitis – Typhoidis – Toxicosis Septicemia – Leptospirosis Rickettsiosis… Epidemiological data, risk evaluation biological analysis, differential diagnostic Contact between clinicians and biologists

CCHF : laboratory data LEUCOPENIA, particularly neutropenia THROMBOCYTOPENIA Hematocrite increases early then falls down ASL, AST levels increases Proteinuria and hematuria Mild azotemia, bilirubine increase

CCHF : laboratory diagnosis Viral detection: blood specimen – RT-PCR (nested) – Cell culture (Vero E 6 cells)

CCHF : laboratory diagnosis Viral detection: (blood specimen) – RT-PCR (nested) – Cell culture (Vero E 6 cells) Antibody detection : (serum sample) - IFA - ELISA Ig. M (immuno-capture) Ig. G - NT

CCHF : laboratory diagnosis Viremia 10 -12 days (although afebrile). Can be detected by PCR up to day 16 By day 9 all patients will have Ig. M or Ig. G antibody Information needed : DATE OF ONSET OF FEVER

CCHF : viral/antibody kinetics Ig. M Ig. G viremia 0 5 10 RT-PCR 16 Viral isolation ELISA Ig. M Ig. G Ig. M duration: 2 -3 months up to 6 months… IFA

Primers for RT-PCR on S segment From J. Smith, 1990

RT-PCR /Southern blot hybridization/antibody : retrospective study Day of illness PCR + Virus + PCR + Virus - 3 1 1 4 1 1 5 3 6 5 3 7 5 4 8 1 2 9 5 10 3 11 1 12 13 1 PCR - Virus + PCR - virus - Ab + 1 Total tested 3 1 2 2 3 5 3 8 15 8 9 4 7 7 1 5 6 3 3 1 5 5 1 1 2 2 4 3 8 8 2 4 1 14 4 1 15 2 1 3 3 16 2 1 3 3 1 1 1 22 65 80 18 Total 18 34 6 From Burt et al, J Virol Methods 1998, 70: 129137

RT-PCR /Southern blot hybridization/IFA antibody : 26 samples from 19 patients from day 3 -12 of illness day of illness 3 PCR + Virus + PCR + Virus - PCR - Virus + PCR - virus - IFA Ab + 1 4 Total tested 1 1 1 5 1 6 4 1 7 3 1 8 6 1 9 1 2 5 1 5 5 2 8 9 2 2 2 10 11 1 12 1 1 1 8 19 26 Total 14 1 3 From : Burt et al, J Virol Methods 1998, 70: 129 -137

Hyalomma sp. ticks RT-PCR Viral isolation

536 pb amplicons of the S fragment of CCHF genome using primers CSDR 3/CSDF 2. RFLP with Hinf I, Hae III, and Alu I endonucleases PROFIL RFLP ORIGINE 321 Grèce An. D 15786 111 Sénégal Ar. D 8194 131 Sénégal Ar. Teh 193 -3 131 Iran HD 49199 131 Mauritanie Ar. Mg 951 123 Madagascar C 68031 224 Chine Ar. B 604 223 Rép. Centrafr. HD 38562 223 Burkina Faso Ar. D 39554 222 Mauritanie Ar. D 97264 222 Sénégal Ar. D 97268 222 Sénégal DUGBE AP 92 (100) (96) (57) (84) (100) (99) (100) HAZARA Rapport IP Dakar 1993

Turkey 2003 Phylogenetic analysis of 46 partial sequences (219 bp) of the S segment of CCHF virus

Phylogenetic analysis of 46 partial sequences (219 bp) of the S segment of CCHF virus. Seven major genetic groups. Strains from the Middle and Far East and from different African regions cluster in clearly separated groups. TURKEY 2003 Preliminary data: 96 -98% homology with strains from the Balck Sea area and Kosovo KOSOVO AF 404507; STAVROPOL AF 481802 ; DROSDOV U 88412 ; ROSTOV AY 277672 Drostein et al, J Clin Microbiol 2002, 40 1122

National Reference Center - WHO Collaborating Centre for Arboviruses and Viral Haemorrhagic Fevers, Institut Pasteur, Lyon Marie-Claude Georges Isabelle Schuffenecker Ingrid Marendat Séverine Murri Hervé Zeller BSL 3 BSL 4