LETTERS detected during the early febrile peri- 2. De Wazieres B, Gil H, Vuitton DA, Dupond by ticks. Hyalomma ticks, the primary od. The male patient still had fever JL. Nosocomial transmission of dengue vectors in CCHF transmission, are from a needlestick injury. Lancet. when the needle accident occurred, 1998;351:498. widespread throughout Europe, Asia, and the needle was contaminated. 3. Langgartner J, Audebert F, Schölmerich J, the Middle East, and Africa; evidence Infectious disease specialists and Glück T. Dengue virus infection transmit- of CCHF virus has been found in all other physicians should recognize that ted by needle stick injury. J Infect. these regions. CCHF in humans is an 2002;44:269–70. vector-borne diseases, such as dengue 4. Hirsch JF, Deschamps C, Lhuillier M. acute viral disease that is transmitted and malaria, are potentially life threat- Metropolitan transmission of dengue by by the bite of infected ticks, direct ening. Therefore, they should consider accidental inoculation at a hospital. Ann contact with blood or infected tissues these diseases in the differential diag- Med Interne. 1990;141:629. from viremic animals, and direct con- 5. Rigau-Perez JG, Vomdam AV, Clark GG. nosis of febrile patients returning from The dengue and dengue hemorrhagic fever tact with the blood or secretions of an tropical countries. In most patients, epidemic in Puerto Rico, 1994–1995. Am J infected person (1). dengue fever resolves without hemo- Trop Med Hyg. 2001;64:67–74. On January 26, 2003, a 22-year- concentration, an indication of dengue 6. Kalayanarooj S, Vaughn DW, Nimmannitya old shepherd was treated at a health S, Green S, Suntayakorn S, Kunentrasai N, hemorrhagic fever. Nosocomial trans- et al. Early clinical and laboratory indica- post in the Popenguine District, 60 km mission of dengue viruses is not a tors of acute dengue illness. J Infect Dis. south of Dakar, Sénégal; he reported common event, however, physicians 1997;176:313–21. fever, epistaxis, arthralgia, myalgia of must consider these diseases. 7. Pandey BD, Igarashi A. Severity-related the lower limbs, and dark urine for the molecular differences among nineteen These unique cases demonstrate strains of dengue-type 2 viruses. Microbiol past 2 days. Without biologic confir- the possible introduction and trans- Immunol. 2000;44:179–88. mation of the infection, he was treated mission of exotic tropical viruses in a 8. Kuberski T, Rosen L, Reed D, Mataika J. for malaria with two intravenous country within temperate zones; all Clinical and laboratory observations on injections of quinine, followed by oral patients with primary and secondary that is needed are competent vectors. dengue type 1 infections with hemorrhagic administration of chloroquine. Whereas A. aegypti is not endemic in manifestations in Fiji. Am J Trop Med Hyg. On January 31, the patient had a Europe, it could be introduced. The A. 1977;26:775–83. temperature of 39°C, conjunctival albopictus mosquitoes, an invader 9. Vaughn DW, Green S, Kalayanorooj S, jaundice, bleeding gums, and was Innis BL, Nimmanitya S, Suntayakorn S, et from Asia, already exists there, albeit al. A dengue in the early febrile phase: vomiting blood. He was seen again at in isolated areas (10). Patients return- viremia and antibody responses. J Infect the health post and was given antimi- ing from distant regions should be Dis. 1997;176:322–30. crobial drugs, intravenous quinine, treated with increased attention and 10. Romi R, Pontuale G, Clufolini MG, and vitamin K; the next day, the Fiorentini G, Marchi A, Nicoletti L, et al. care. Although dengue viruses are Potential vectors of West Nile virus follow- bleeding stopped and the fever sub- rarely transmitted person to person, ing an equine disease outbreak in Italy. Med sided. A serum sample was sent to the this incident emphasizes the impor- Vet Entomol. 2004;18:14–19. World Health Organization tance of having reliable and rapid Collaborative Centre for Arboviruses diagnostic methods available for early Address for correspondence: Zsuzsanna and Viral Hemorrhagic Fevers at the detection of imported infections with Nemes, Department of Infectology, Baranya Institut Pasteur, Dakar. Tests for anti- exotic viral agents. County Hospital, Pécs, 7623 Pécs, Rákoczi u. 2, CCHF specific immunoglobulin (Ig) Hungary; fax: 36-72-213025; email: zsuzsan- M antibody by enzyme-linked Zsuzsanna Nemes,* [email protected] immunosorbent assay (ELISA) were Gabriella Kiss,* Edit P. Madarassi,* positive, and CCHF virus by isolation Zoltán Peterfi,* Emoke Ferenczi,† on cell cultures (AP61 and Vero cells) Tamas Bakonyi,‡§ and reverse transcriptase-polymerase and Gabor Ternak* chain reaction (RT-PCR) were nega- *County Hospital, Pécs, Hungary; †Johan Human tive. From January 31 to February 10, Bela National Center for Epidemiology, the IgM titer increased from 1/3,200 Budapest, Hungary; ‡University of Crimean-Congo > Veterinary Medicine, Vienna, Austria; and to 1/12,800 and IgG titer increased §Szent Istvan University, Budapest, Hemorrhagic from 1/200 to 1/6,400. Hungary Fever, Sénégal Examination of the patient on February 10 showed he had recovered References To the Editor: Crimean-Congo without sequelae, and no trace of tick hemorrhagic fever (CCHF) virus, bites was found. The patient stated 1. Guzman MG, Kouri G. Dengue: an update. Lancet Infect Dis. 2001;2:33–42. genus Nairovirus, family Bunyviridae, that he had not traveled, noticed any is transmitted to mammals and birds tick bites, slaughtered any animals, or

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 10, October 2004 1881 LETTERS been in contact with people with fever Pierre Nabeth,* Moussa Thior,† travel from the United Kingdom to for several weeks before his illness. Ousmane Faye,* Makkah, Saudi Arabia; of those, He lived in close proximity to goats and François Simon* approximately 1,000 person reside in and cattle, but no blood samples were *Institut Pasteur de Dakar, Dakar, Sénégal; the east end of London. In the past, taken from these animals. Although and †Centre de santé, Popenguine, infectious diseases research conduct- no ticks were found on nearby goats, Sénégal ed during these pilgrimages focused 10 Amblyomma and Hyalomma ticks on meningococcal disease because of were collected from three cattle. Ticks References outbreaks associated with the hajj. were negative for CCHF virus isola- 1. Hoogstraal H. The epidemiology of tick- Since 2000, the dates of the hajj have tion on suckling mice and RT-PCR borne Crimean-Congo hemorrhagic fever been moved back into the winter sea- amplification. in Asia, Europe and Africa. J Med Entomol. son; this time change could lead to a 1978;15:307–417. No other case of fever accompa- 2. Chunikhin SP, Chumakov MP, Butenko seasonal increase in outbreaks of res- nied by hemorrhage was reported in AM, Smirnova SE, Taufflieb R, Camicas piratory infections caused by influen- the area, and none of the patient’s 14 JL, et al. Results from investigating human za and other viruses. From 1991 to close contacts became ill. Of the four and domestic and wild animal blood sera in 1992, influenza A was a common the Sénégal Republic (western Africa) for close contacts from whom blood sam- antibodies to Crimean hemorrhagic fever cause of respiratory infection in pil- ples were taken, analyses for IgM and virus. Mater.16. Nauchn.Sess.Inst.Polio. grims tested in Makkah (1). However, IgG antibodies against CCHF virus Virus.Entsefalitov (Moscow, October 1969) the incidence rate of influenza among were negative by ELISA. 2, 158–60. 1969. NAMRU3-T810 (in pilgrims from Europe is not well- English). While no clinical case of CCHF 3. Wilson ML, LeGuenno B, Guillaud M, known. A previous study of influenza- has ever been reported in Senegal, Desoutter D, Gonzalez JP, Camicas JL. like illness among pilgrims from studies dating from 1969 indicate that Distribution of Crimean-Congo hemorrhag- Pakistan reported rates of 36% in CCHF virus had been found in vari- ic fever viral antibody in Sénégal: environ- influenza-vaccinated pilgrims and mental and vectorial correlates. Am J Trop ous locations in the country (2,3). In Med Hyg. 1990;43:557–66. 62% in influenza-nonvaccinated pil- the village of Bandia, in the same dis- 4. Wilson ML, Gonzalez JP, LeGuenno B, grims; these results were based on trict where the reported case was Cornet JP, Guillaud M, Calvo MA, et al. clinical endpoints without microbio- observed, a study conducted from Epidemiology of Crimean-Congo hemor- logic confirmation (2). rhagic fever in Sénégal: temporal and spa- 1986 to 1988 showed a prevalence of tial patterns. Arch Virol.1990;Suppl We assessed the risk for influenza anti-CCHF IgG of 3.2% in the human 1:323–40 infection among a cohort of pilgrims population (4). Another study, con- 5. Zeller HG, Cornet JP, Diop A, Camicas JL. from the east end of London who par- ducted in the same area from 1989 to Crimean-Congo hemorrhagic fever in ticks ticipated in the hajj in 2003. From (Acari: Ixodidae) and ruminants: field 1992, showed seroconversions for observations of an epizootic in Bandia, December 2002 to January 2003, we several ruminants and isolated the Sénégal (1989–1992). J Med Entomol. enrolled 115 participants who planned virus from ticks (5). 1997; 4:511–6. to take part in hajj in 2003. The During CCHF outbreaks, an aver- study was approved by the North age of 30% of people who had the dis- Address for correspondence: Pierre Nabeth, London Multicentre Research Ethics ease died (case-fatality ratio). It is Institut Pasteur de Dakar, 36 Avenue Pasteur, Committee and the Trustees of East often discovered during nosocomial BP 220, Dakar, Sénégal; fax: +221 839 92 10; London Mosque. Informed consent outbreaks, as was the case in email: [email protected] was obtained through appropriate Mauritania, a country on Sénégal’s translators. All participants attended northern border, in 2003 (P. Nabeth, the East London Mosque, White- unpub. data). To prevent outbreaks of chapel, London; 30 were vaccinated CCHF, public awareness campaigns with influenza vaccine (A/New aimed at the populations most at Caledonia/20/99 [H1N1]-like strain, A risk—livestock farmers, butchers, and /Moscow/10/99 [H3N2]-like strain, health personnel—must be conduct- Influenza among B/Sichuan/379/99-like strain). Venous ed, and the epidemiologic alert sys- U.K. Pilgrims to blood samples were collected, and tems must be strengthened. In addi- Hajj, 2003 questionnaires were completed before tion, conditions that enhance mainte- the participants departed for the hajj nance of the virus in nature and its To the Editor: Each year, approx- and within 2–3 weeks of their return in transmission to humans must be better imately 2 million Muslims travel from February to March 2003. understood so adequate control meas- all over the world to participate in Tests for influenza A and B were ures can be developed. hajj. Approximately 22,000 pilgrims conducted by using hemagglutination

1882 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 10, October 2004