Knowledge, attitude and perceptions about Crimean Congo Haemorrhagic Fever (CCHF) among occupationally high-risk healthcare professionals of Pakistan

Control strategies for emerging infectious diseases: Crimean-Congo hemorrhagic fever management

Background and Aims

Crimean-Congo Hemorrhagic Fever (CCHF) is a significant public health concern transmitted by ticks. This study seeks to thoroughly grasp the epidemiology and transmission patterns of CCHF, which is caused by the CCHF virus (CCHFV), a member of the Nairovirus genus in the Bunyaviridae family.

Methods

The study investigates the global distribution and endemicity of CCHF, its mortality rates, modes of transmission (including tick bites, contact with infected animal blood, and limited person-to-person transmission), and factors influencing its prevalence across different regions. Genetic diversity within CCHFV and its impact on transmission dynamics are explored, along with efforts to control the disease through tick prevention, antiviral treatment, and the development of vaccines and diagnostics.

Results

CCHFV exhibits widespread distribution, particularly in the Middle East, Africa, Asia, and Eastern Europe, with an overall mortality rate of approximately 30% and a case fatality rate ranging from 10% to 40%. Transmission occurs primarily through tick bites and contact with infected animal blood, with limited person-to-person transmission. Livestock workers, slaughterhouse employees, and animal herders in endemic areas are most affected by their frequent interaction with sick animals and ticks. Genetic diversity within CCHFV contributes to variations in transmission dynamics, complicating control efforts. Antiviral ribavirin shows efficacy in treating CCHF infection.

Conclusion

This study underscores the importance of further research to understand the enzootic environment, transmission routes, and genetic diversity of CCHFV for effective control measures, including the development of vaccines, treatment options, and diagnostics.

Large-Scale Serological Survey of Crimean-Congo Hemorrhagic Fever Virus and Rift Valley Fever Virus in Small Ruminants in Senegal

Crimean-Congo hemorrhagic fever (CCHF) and Rift Valley fever (RVF) are among the list of emerging zoonotic diseases that require special attention and priority. RVF is one of the six priority diseases selected by the Senegalese government. Repeated epidemic episodes and sporadic cases of CCHF and RVF in Senegal motivated this study, involving a national cross-sectional serological survey to assess the distribution of the two diseases in this country throughout the small ruminant population. A total of 2127 sera from small ruminants (goat and sheep) were collected in all regions of Senegal. The overall seroprevalence of CCHF and RVF was 14.1% (IC 95%: 12.5-15.5) and 4.4% (95% CI: 3.5-5.3), respectively. The regions of Saint-Louis (38.4%; 95% CI: 30.4-46.2), Kolda (28.3%; 95% CI: 20.9-35.7), Tambacounda (22.2%; 95% CI: 15.8-28.6) and Kédougou (20.9%; 95% CI: 14.4-27.4) were the most affected areas. The risk factors identified during this study show that the age, species and sex of the animals are key factors in determining exposure to these two viruses. This study confirms the active circulation of CCHF in Senegal and provides important and consistent data that can be used to improve the surveillance strategy of a two-in-one health approach to zoonoses.

Predictors of Mortality in Crimean-Congo Hemorrhagic Fever Patients Admitted at a Tertiary Care Hospital in Pakistan over the Last 10 Years: A Case-Control Study

The objective was to identify predictors of mortality in hospitalized patients with Crimean-Congo hemorrhagic fever (CCHF). A case-control study was conducted on patients hospitalized with CCHF from 2012 to 2022. Risk factors for mortality in CCHF patients were analyzed using logistic regression. A total of 86 patients with a median age of 36 years (interquartile range [IQR], 27-36 years) were included, and the majority were males (78, 90.7%). Thirty-one patients (36%) were cases, whereas 55 (64%) were control patients. Based on univariate logistic regression analysis, patients who were in an age group of ≥40 years (odds ratio [OR]: 4.85; 95% CI: 1.8-12.4) or with presence of gum bleeding (OR: 2.66; 95% CI: 1.0-6.8), unit increase in white blood cell count (WBC) (OR: 1.09; 95% CI: 1.00-1.07), serum glutamate-pyruvate transaminase of ≥500 U/L (OR: 3.68; 95% CI: 1.4-9.3), serum glutamic-oxaloacetic transaminase (SGOT) of ≥1,000 U/L (OR: 8.72; 95% CI: 2.6-28.3), prothrombin time (PT) of ≥120 seconds (OR: 9.85; 95% CI: 3.2-29.8), international normalized ratio of ≥5 (OR: 15.8; 95% CI: 2.0-125.3), or acute respiratory distress syndrome (ARDS) (OR: 28.27; 95% CI: 5.84-136.9) were found to be significantly associated with mortality in CCHF. Factors found to be independently associated with mortality on multivariate analysis included ARDS (adjusted OR [aOR]: 27.7; 95% CI: 4.0-190.5), unit increase in WBC (aOR: 1.02; 95% CI: 1.02-1.26), SGOT of ≥1,000 U/L (aOR: 23.6; 95% CI: 2.32-241.7), and PT of ≥120 seconds (OR: 10.2; 95% CI: 2.00-52.4). CCHF is a rare but fatal disease, and patients with ARDS and increased WBC, high SGOT level, and increased PT indicative of liver injury and coagulopathy at the time of hospitalization are at high risk for mortality.

Knowledge, attitude, and perceptions of healthcare professionals towards complementary and alternative medicine: a cross-sectional survey from twin cities of Pakistan

BACKGROUND

The growing popularity and use of complementary and alternative medicine (CAM) products among the general public worldwide has been well documented. This study aimed to investigate the knowledge, attitude, and perceptions (KAP) of Pakistani healthcare professionals (HCP) toward CAM and to document their views on integrating CAM education with the curriculum of undergraduate health science programs.

METHOD

A cross-sectional study using simple random sampling was conducted for a duration of ten months among HCPs from Pakistan's twin cities: Islamabad and RawalpindiThe data were collected using a self-administered and validated (Cronbach's alpha: 0.71) questionnaire. This questionnaire consisted of five sections, namely; demographic, attitude, perception, integration and knowledge.

RESULT

The response rate was 91.20% (500/456). The participants included 160 physicians, 155 nurses,and 141 pharmacists. The majority of the respondents were females, 67.50%, and unmarried (60.50%).The majority of HCPs participating in this study agreed that CAM modalities may benefit conventional medicine system. Likewise, most HCPs perceived different CAM therapies aseffective treatment options. More than 50% HCPs suggested CAM elective courses in the curriculum of the health sciences program.Overall, 79.17% of the HCPs have poor knowledge of CAM. Physicians have the highest knowledge score 25.63%, followed by pharmacists 21.99%, and nurses 12.26%. Knowledge status was significantly associated with age, profession, and experience of practice (p = 0.001,0.001 & 0.019).

CONCLUSION

This study revealed that despite the overall positive attitude of HCPs toward CAM, the score of knowledge is low. Therefore, the survey recommends evidence-based guidelines for the rationale use of CAM and updated syllabi of undergraduate health programs which will assist the future HCPs in increasing professionals' knowledge toachieve better health outcomes for the general public.

Socio-demographic determinants of Monkeypox virus preventive behavior: A cross-sectional study in Pakistan

BACKGROUND

Monkeypox (mpox), re-emerging zoonotic infectious disease, is striking the world with serious public health concerns, especially in non-endemic countries. The public's knowledge and attitude towards the monkeypox virus (MPXV) influence their adherence to preventive strategies. Therefore, we aimed to assess the public's knowledge, attitudes, and perceptions (KAP) of MPXV in Pakistan.

METHODS

We collected data for this cross-sectional study from 1040 participants via online self-reported questionnaire from July 5th, 2022, to August 1st, 2022. The questionnaire consisted of a total of 29 items in four sections, assessing socio-demographics, knowledge, attitudes, and practices regarding MPXV. The data were analyzed using IBM SPSS V.25, and factors associated with MPXV knowledge, attitude, and practices were identified by using logistic regression analyses.

RESULTS

A total of 1040 participants were included. 61.4% were male, and 57.2% had graduation level education. Only 34.4% had good knowledge about MPXV, and 30% knew the effectiveness of the smallpox vaccine against MPXV. 41.7% had a positive attitude, 48.6% agreed that it is a fatal disease, and 44.6% were in favour of banning travel from endemic to non-endemic regions. 57.7% had good practices, and 69.9% would use protective measures if MPXV became an epidemic. Binary logistic regression analysis revealed that gender and education significantly impacted knowledge (p<0.05). While monthly income status had a significant impact on attitudes (p<0.05). The practices were positively correlated with gender and education (p<0.05).

CONCLUSION

The majority of study participants had inadequate levels of knowledge, and attitudes regarding MPXV. To prevent the emergence and spread of MPXV in Pakistan, a comprehensive strategic framework for public health education must be established and implemented.

Crimean-Congo Hemorrhagic Fever Presented in Dengue Epidemic: A Case Report

In Pakistan, hemorrhagic diseases, including dengue and Crimean-Congo hemorrhagic fever (CCHF), are common. Therefore, an accurate diagnosis is challenging in the early stages of sickness owing to geographic overlap and early clinical similarities between the two disorders. A 35-year-old man who had previously experienced hematemesis and high-grade fever presented to our hospital. Despite receiving supportive care for a preliminary diagnosis of dengue hemorrhagic fever, the patient's condition worsened. The results of the dengue IgM antibody test were negative. On the fourth day of admission, a qualitative polymerase chain reaction test for CCHF virus RNA was performed, and the result returned positive. All medical personnel and attendants who had contact with the patient had to receive ribavirin prophylaxis, which required significant investment in resources. Because CCHF can have long-term financial and health repercussions for contacts, including healthcare personnel in developing nations, it is essential to identify and treat it as soon as possible. It is necessary to keep track of dengue and CCHF cases more closely to develop predictors of disease diagnosis that are reasonably trustworthy, affordable, and quick. These predictors can aid in directing future choices regarding the care of similar situations. Ultimately, such an approach might result in improved cost control in environments with limited resources. Consideration should also be given to patients who receive ribavirin prophylaxis.

Distribution pattern of Crimean-Congo Hemorrhagic Fever in Asia and the Middle East

Crimean-Congo Hemorrhagic Fever (CCHF) is one of the most important vector-borne diseases of zoonotic potential that can be acquired following the bite of the Hyalomma species of ticks. It is a highly prevalent disease in Asia and the Middle East. The risk factors of this disease are contact with infected tissue, blood, patient, or livestock in the acute viremic phase, infected tick bites, or the manual removal of ticks. The disease is clinically described as progressive hemorrhages, fever, and pain in musculature. Biochemical tests reveal elevated levels of creatinine phosphokinase, alanine transaminase, aspartate aminotransferase, and lactate dehydrogenase. Clotting time is prolonged in pro-thrombin tests, and pathogenesis is mostly related to the disruption of the epithelium during viral replication and indirectly by secreting cytotoxic molecules. These molecules cause endothelial activation and result in the loss of function. Supportive therapy is given through blood or plasma infusions to treat or manage the patients. According to the most advanced studies, CCHF can be treated by Ribavirin, which is an antiviral drug that shows excellent results in preventing the disease. Health-care staff are more prone to infection. The hemorrhagic phase represents a high risk for accidental exposures. This literature review presents a comprehensive overview of the viral epidemiology, zoonotic perspectives, and significant risk factors of CCHF in various Middle East and Asian countries. Furthermore, the pathophysiology and preventive strategies of CCHF have also been discussed as well as legislation and policies regarding public outreach programs, research, and development aimed at infection prevention and control that are required at a global level.

Crimean-Congo hemorrhagic fever outbreak in Pakistan, 2022: A warning bell amidst unprecedented floods and COVID 19 pandemic

Crimean-Congo hemorrhagic fever (CCHF) is an infection caused by a tick-borne virus (genus: Nairovirus, family: Bunyaviridae). The most important vector for CCHF is the ixodid tick. Along with tick bite, direct contact with the virus-affected animal is responsible for its spread. Pakistan witnessed its first case of CCHF in 1976 and has been a major victim of CCHF for years, but spikes in cases are seen after Eid-ul-Adha, an Islamic festival involving the sacrifice of cattle. The disease, in particular, is common among butchers, veterinarians, and livestock workers. From the start of this year till June 22, 2022, a total of four cases have been reported across the country. Pakistan faces major challenges in combating CCHF every year due to its specific geographical position and a majority of the population being involved with animal husbandry. There is no approved vaccine for its prevention. All these factors contribute to the burden on the already weakened healthcare system of Pakistan. Strict actions should be taken to contain the spread of the disease. The need of the hour is to engage the general population, raise awareness, and develop policies to ensure disease surveillance. This should be accompanied by fostering collaboration among animal and human health departments for efficient communication and early intervention. The focus should be on medical research to find an efficacious treatment and prophylaxis for the CCHF virus, which will be the cornerstone of future CCHF prevention and control strategies.

The impact of COVID-19 followed by extreme flooding on vector borne diseases in Pakistan: A mini narrative review

While the Coronavirus pandemic continues to spread havoc across the world, countries like Pakistan are faced with another challenge: the steady rise of vector borne diseases alongside a spike in COVID-19 cases. Moreover, signs and clinical manifestations of multiple arbovirus infections mimic those experienced in COVID-19, causing further complications in management and diagnosis. Without urgent adequate management and testing equipment, the recent surge of COVID-19 along with the steady rise in Vector Borne Diseases (VBDs) could collapse the exhausted Pakistani healthcare system. This article explores the impact of COVID-19 on the management, diagnosis, and treatment of the common arbovirus infections of Pakistan, including dengue (DENV), malaria, chikungunya (CHIKV), and other foreign infections that are on a hazardous rise.

Knowledge, attitudes, and practices regarding Crimean-Congo hemorrhagic fever among general people: A cross-sectional study in Pakistan

Background

Crimean-Congo hemorrhagic fever (CCHF) continues to pose a serious threat to the fragile healthcare system of Pakistan with a continuous increase of morbidity and mortality. The present study aimed to assess the knowledge, attitudes, and practices regarding CCHF among general people who resided in Pakistan.

Methods

An online cross-sectional survey design was applied, and a convenience sampling technique was used to recruit 1039 adult people from Pakistan. Data were collected from September 08 to October 12, 2021. The questionnaire consisted of a total of 32 questions in four parts assessing socio-demographics, as well as knowledge, attitudes, and practices regarding CCHF. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS), and logistic regression analyses were performed to determine the factors associated with good knowledge, positive attitudes, and good practices.

Results

Alarmingly, 51.5% of participants heard about CCHF infection before administering the survey. Among these, 20.2%, 33.3%, and 48.2% of the study participants had demonstrated good knowledge, positive attitudes, and good practices, respectively. Binary logistic regression analysis revealed that education and income status had a significant impact on knowledge and attitudes (p<0.05). Similarly, the mean attitude scores differed significantly by age, education, and income status (p<0.05).

Conclusions

The findings reflected inadequate levels of knowledge, attitudes, and practices regarding CCHF among general people in Pakistan which may regard as lower than expected. As CCHF is a highly contagious disease, it’s urgent to initiate a comprehensive approach to handle the situation before it spreads further in Pakistan.

Excessive Daytime Sleepiness and Sleep Quality and their Impact on Health-Related Quality of Life in People with Epilepsy: A study from Pakistan

BACKGROUND

Epilepsy is one of the most common but manageable neurological disorder. The relation between epilepsy, sleep, and health-related quality of life (HRQoL) in culturally distinct environment of Pakistan remains unclear. The purpose of this study was to determine prevalence and predictors of excessive daytime sleepiness (EDS), poor sleep quality (SQ), and to analyze their association with HRQoL in people with epilepsy (PWE).

METHODS

A study was conducted among PWE attending two tertiary care hospitals of Islamabad and Rawalpindi, Pakistan. The EDS, SQ, and HRQoL were evaluated by Urdu versions of Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), and Quality of Life in Epilepsy-31 (QOLIE-31).

RESULTS

The study included 200 PWE and 51 healthy controls with mean (SD) ages of 33.1 ± 13.9, 32.9 ± 10.9, and a disease duration of 5.01 ± 6.17, respectively. The majority of the respondents (n = 130, 65%) had poor seizure control, and most of these (n = 88, 68%) were on combination antiepileptic drug (AED) therapy. In comparison to controls, a higher number of PWE had EDS by ESS (score ≥ 11, 10% vs. 40%, p-value 0.00), and poor SQ by PSQI (score > 5, 9% vs. 71%, p-value 0.00). A multiple logistic regression analysis reveals that the factors significantly associated with EDS were: female gender; increasing age; seizure control; duration of epilepsy; and combination AED therapy. A second multiple binary logistic regression analysis suggests that factors significantly associated with poor SQ were: increasing age; female gender; poor seizure control; and combination therapy. The Hierarchical multivariate analysis suggests that poor seizure control, EDS, and poor SQ were significant predictors of low HRQoL.

CONCLUSION

The findings suggest high prevalence of EDS and poor SQ in PWE in Pakistan. A significant negative association exists between sleep complaints and HRQoL. During routine clinical consultations, awareness about sleep hygiene practices must be provided to enhance HRQoL.

Barriers and Enablers for Adherence to Antiretroviral Therapy Among People Living With HIV/AIDS in the Era of COVID-19: A Qualitative Study From Pakistan

Background: With the increased availability of safe antiretroviral therapy (ART) in recent years, achieving optimal adherence and patient retention is becoming the biggest challenge for people living with HIV (PLWH). Care retention is influenced by several socioeconomic, socio-cultural, and government policies during the COVID-19 pandemic. Therefore, we aim to explore barriers and facilitators to adherence to ART among PLWH in Pakistan in general and COVID-19 pandemic related in particular.

Methods: Semi-structured interviews were conducted among 25 PLWH from December 2020 to April 2021 in the local language (Urdu) at the ART centre of Pakistan Institute of Medical Sciences, Islamabad, Pakistan. Interviews were audio-recorded in the local Urdu language, and bilingual expert (English, Urdu) transcribed verbatim, coded for themes and sub-themes, and analyzed using a phenomenological approach for thematic content analysis.

Results: Stigma and discrimination, fear of HIV disclosure, economic constraints, forgetfulness, religion (Ramadan, spiritual healing), adverse drug reactions, lack of social support, alternative therapies, and COVID-19-related lock-down and fear of lesser COVID-19 care due to HIV associated stigma were identified as barriers affecting the retention in HIV care. At the same time, positive social support, family responsibilities, use of reminders, the beneficial impact of ART, and initiation of telephone consultations, courier delivery, and long-term delivery of antiretrovirals during COVID-19 were identified as facilitators of HIV retention.

Conclusion: Improving adherence and retention is even more challenging due to COVID-19; therefore, it requires the integration of enhanced access to treatment with improved employment and social support. HIV care providers must understand these reported factors comprehensively and treat patients accordingly to ensure the continuum of HIV care. A coordinated approach including different stakeholders is required to facilitate patient retention in HIV care and consequently improve the clinical outcomes of PLWH.

Stigma, Social Support, Illicit Drug Use, and Other Predictors of Anxiety and Depression Among HIV/AIDS Patients in Pakistan: A Cross-Sectional Study

Introduction: Anxiety and depression in people living with HIV/AIDS (PLWHA) can lead to non-adherence to antiretroviral therapy (ART), morbidity, and mortality. Therefore, assessing the stigma, social support, and other determinants of anxiety and depression in PLWHA are important for developing further interventions. Methods: An institution-based cross-sectional study was conducted in 505 PLWHA, approached through systematic sampling, who paid routine visits to the ART center, Pakistan Institute of Medical Sciences (PIMS), Islamabad. Data was collected by pretested validated hospital anxiety and depression scale (HADS). Version 26 of the SPSS was used to apply Logistic regression analysis to identify determinants, and the 95% confidence interval (CI) adjusted odds ratio (AOR) was calculated to assess the magnitude of the relationships. Results: In PLWHA, the prevalence of co-morbid depression and anxiety was 80%. Separately, 89.9% had depression, and 80.3% had anxiety. Use of illicit drugs [AOR = 1.87, 95% CI (1.01, 3.27)], low social support [AOR = 1.21, 95% CI (1.02, 2.25)], being male [AOR = 2.21, 95% CI (1.11, 5.49)], and HIV related stigma [AOR = 2.48, 95% CI (1.25, 6.02)] were significant predictors of depression. Having detectable viral load [AOR = 3.04, 95% CI (1.04, 8.86)], young age [AOR = 5.31, 95% CI (1.19, 29.39)], no formal education [AOR = 21.78, 95% CI (4.03, 117.62)], low [AOR = 1.70, 95% CI (1.12, 6.93)] or moderate [AOR = 2.20, 95% CI (1.79, 6.09)] social support, illicit drugs addiction [AOR = 1.17, 95% CI (1.03, 2.55)], and HIV stigma [AOR = 54.3, 95% CI (21.20, 139.32)] had a remarkable association with anxiety. Conclusions: Given the high prevalence of anxiety and depression among PLWHA, the Pakistan Ministry of Health should focus more on monitoring mental health, expanding mental health services, and developing interventions based on identified factors to treat depression and anxiety among PLWHA.

Public Knowledge and Practices Regarding Coronavirus Disease 2019: A Cross-Sectional Survey From Pakistan

Objectives: Effective mitigation of coronavirus diseases (COVID-19) pandemic requires true adoption of precautionary measures by the masses, that primarily depends upon their knowledge and practices behaviors. The current study aimed to assess the knowledge; practices of Pakistani residents regarding COVID-19 and factors associated with adequate knowledge and positive practices. Material and Methods: A cross-sectional online survey was conducted from 15-April 2020 to 20 May 2020 among 689 Pakistanis by using a validated self-administered questionnaire (Cronbach's alpha 0.77). The questionnaire included questions on the assessment of demographics, the source of information, knowledge, and practice of COVID-19 on google forms and shared links with the WhatsApp groups, Facebook pages and other online platforms. Regression analysis was applied to find potential predictors of knowledge and practices. Results: Of 689 participants, 431 (62.6%) were male, 64.3% (n = 443) were aged <30 years, and\328 (47.6%) of participants were married. 48.19% (n = 332) had adequate knowledge; 81% (n = 555) had positive practices regarding COVID-19 and majority (66.62%, n = 459) seek knowledge from social media. Knowledge was significantly higher (OR > 1.00, p < 0.05) among educated and higher income participants. Positive practices were significantly (OR > 1.00, p < 0.05) related to the older age (≥50 years), higher education, higher income and good knowledge regarding COVID-19. Conclusion: The study concluded that Pakistani residents had average knowledge and good practices toward COVID-19 yet there are gaps in specific aspects of knowledge, and practice that should be focused in future awareness and educational campaigns. The study recommends the ministry of health authorities to promote all precautionary and preventive measures of COVID-19-consisting of a better-organized approach to all strata of society: less privileged people, older ones and less educated people, in order to have equilibrium of knowledge about COVID-19; hence effective implementation of precautionary measures.

An Epidemiological Survey Regarding Ticks and Tick-Borne Diseases among Livestock Owners in Punjab, Pakistan: A One Health Context

Recent global changes have led to an increase in the spread of ticks and tick-borne diseases (TBDs) affecting domestic ruminants and humans, with an annual loss of US $13.9–$18.7 billion. The current study determined the perception and practices of livestock farmers regarding tick infestation. A total of 112 livestock farms were surveyed in Punjab, Pakistan, among which animals from 42 (37.5%) farms were infested with ticks. Only 28.6% (n = 32) of the dairy farmers were consulting veterinarians for ticks control, while 86.7% (n = 97) of the respondents did not consider biosecurity measures in the control of tick transmission. Most of the respondents, 71.4% (n = 80), did not consider manual tick removal from their animals (i.e., by hand, followed by physically crushing) as a risky practice for spreading zoonotic diseases. Improper disposal of bottles of acaricides in the farm drainage was also observed, putting the environment and aquatic life at risk. These wrong practices may contribute to high disease burdens and economic losses, increasing the possibility of transmission of zoonotic TBDs and pollution of the environment. Therefore, an integrated One Health approach is required for the control of TBDs through environmentally friendly approaches.