A Newly Emergent Viral Hemorrhagic Fever in Saudi Arabia: Descriptive Epidemiology of Alkhurma Hemorrhagic Fever, 2011-2014 Open Access

Gaw, Zahra Redha (2016)

Permanent URL: https://etd.library.emory.edu/concern/etds/k0698822h?locale=en


Background: The first case of Alkhurma hemorrhagic fever virus (AHFV) was identified in the Kingdom of Saudi Arabia (KSA) in mid-1990s. The first case of AHFV outside Saudi Arabia was detected in south Egypt in 2010. The epidemiology of this virus has yet to be completely determined. We conducted a descriptive epidemiologic assessment of time trends, geographic distribution, and person-related characteristics of cases reported between 2011 and 2014 in the Saudi Arabia.

Methods: A descriptive secondary analysis was conducted of a de-identified dataset collected as a part of the KSA Ministry of Health's (MoH) ongoing AHFV surveillance program from 2011 to 2014. This dataset contained geographic and demographic information (age, gender, nationality and occupation) of laboratory-confirmed cases of AHFV.

Results: A total of 281 laboratory-confirmed cases of AHFV were reported over a period of four years from 2011 - 2014. The number of reported cases decreased from 93 in 2011 to 58 in 2012 and 59 in 2013. The number increased again in 2014 to 71 cases. The monthly distribution of reported cases during the study period revealed two peaks in August and November. Overall, Najran had 75% of all reported cases and it maintained the highest proportion of cases throughout the study period. The ages of cases ranged from one-year-old to 108 years old, with an average age of 37.6 years (standard deviation ± 17.6). The majority of cases were men (63.4%) and Saudi nationals (63.7%). One-third of the cases were housewives and housemaids, 20% held office jobs, and 10.7% worked in jobs that involved direct contact with animals.

Conclusion: Our findings extend existing data on AHFV by providing recent time trends in disease occurrence over a 4-year period. Our results identify Najran as a high-risk area, and housewives and housemaids as a high-risk group. Our study design does not allow for inference on etiology; we had only occupation as an indicator of exposure. Detailed exposure history and analytical studies are needed to characterize modes of transmission and risk factors. Ongoing monitoring of AHFV trends is crucial.

Keywords: Alkhurma Hemorrhagic Fever Virus (AHFV), emerging infections, Saudi Arabia

Table of Contents

Chapter 1: Introduction. 10

Overview of Viral Hemorrhagic Fever. 10

Viral Hemorrhagic Fever in Saudi Arabia: Emergence of Alkhurma Hemorrhagic Fever Virus. 12

Knowledge Gaps in Alkhurma Hemorrhagic Fever Virus. 14

Research Questions. 15

Chapter 2: Literature Review. 16

Emergence of Alkhurma Hemorrhagic Fever Virus in Saudi Arabia, 1995 - 2011. 16

Initial Occurrence. 16

Subsequent Occurrences. 17

Appearance Outside Saudi Arabia. 19

Seasonal Patterns. 20

Modes of Transmission. 21

Risk Factors. 23

Clinical Manifestations and Outcomes. 25

Disease Surveillance System in Saudi Arabia. 26

Saudi Arabia: Geography and Regions. 26

AHFV Surveillance System Structure. 27

Case Definition. 28

Abstract. 31

Introduction. 32

Methods. 33

Surveillance System of Alkhurma Hemorrhagic Fever Virus in Saudi Arabia. 33

Data Sources. 34

Case Definition. 34

Study Variables. 34

Statistical Analysis. 36

Ethics. 36

Results. 37

Descriptive Analysis. 37

Annual and monthly trend of AHFV cases. 37

Region. 37

Age. 38

Nationality and Gender. 38

Occupation. 38

Bivariate Analysis. 38

Case Fatality Rate. 40

Discussion. 40

Chapter 4: Conclusion and Recommendations. 48

Conclusion. 48

Recommendations. 49

References. 51

Appendix: Figures and Tables. 53

Figure 1: Map of Kingdome of Saudi Arabia, with regions where Alkhurma Hemorrhagic Fever Virus cases were reported (represent by red spot). 53

Figure 2: The monthly distribution of Alkhurma Hemorrhagic Fever Virus over four years period in Saudi Arabia (2011-2014). 54

· 2A: Year 2011

· 2B: Year 2012

· 2C: Year 2013

· 2D: Year 2014

Table 1: Demographic characteristic of patients with Alkhurma Hemorrhagic Fever Virus in Saudi Arabia by year (2011-2014). 55

Table 2: Demographic characteristics of patient with Alkhurma Hemorrhagic Fever Virus in Saudi Arabia by nationality (2011-2014). 56

Table 3: Mean Age and Gender Distribution among Occupation Groups with Alkhurma Hemorrhagic Fever Virus in Saudi Arabia (2011-2014). 57

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