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Archived Comments for: Steady improvement of infection control services in six community hospitals in Makkah following annual audits during Hajj for four consecutive years

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  1. Alkhurma hemorrhagic fever virus, an emerging tick-borne flavivirus

    Remi Charrel, Unite des Virus Emergents, Universite de la mediterranee

    25 September 2006

    Alkhurma hemorrhagic fever virus, an emerging tick-borne flavivirus

    In his recent article, “Steady improvement of infection control services in six community hospitals in Makkah following annual audits during Hajj for four consecutive years”— BMC Infectious Diseases (2006) 51, 91–97,(1) Madani and collaborators states that “… 37 cases of a novel viral hemorrhagic fever virus, referred to as Alkhumra virus, were reported solely from Makkah in 2001-2002, and the virus was also believed to be transmitted by mosquito bitesand/or direct contact with infected sheep”. We do not agree with this statement and would to comment on several points.

    First, although Alkhurma hemorrhagic fever virus (AHFV) cause hemorrhagic fever, other clinical manifestations such as central nervous manifestations (seizures, coma, encephalitis) and hypotensive shock must be kept in mind since they are frequently associated with pejorative outcome even in the absence of hemorrhages (2).

    Second, out of a total of 16 cases proven by virus isolation, eleven cases occurred in patients living in Jeddah and one in a patient living in Al-Taief (2, 3). More recently, a case was diagnosed in a patient originating from Najran, well beyond the Makkah-Jeddah axis and close to the Yemeni border (4). This demonstrates that AHFV cases are not restricted to Makkah, and strongly suggest that geographic distribution may be larger than initially thought, and could cover areas outside of Saudi Arabia.

    Third, although the suggested role of mosquitoes in AHFV transmission is an interesting hypothesis, no experimental of field data were presented by Madani et al. (2006) or by others so far. In contrast, the tick-borne nature of AHFV is supported by several evidence: (i) AHFV is genetically and serologically more closely related to tick-borne flaviviruses.(3, 5, 6); (ii) all the 16 AHFV cases previously reported (2, 3) occurred during seasonal peak of tick feeding activity (May–October); (iii) Tick bite has also been associated with clinical cases.(3); (iv) AHFV RNA was recently detected in ticks collected on a camel resting place in Jeddah (Charrel and Fagbo, personal data; comparison of sequences obtained from human and tick (acc no DQ154114) indicated that they originated from a common ancestor. Tick-borne flaviviruses can also infect humans via direct contact with infected blood (occupational risk) or by the consumption of raw milk (7,8) Altogether, this data pleads for a tick transmission rather than mosquito transmission for AHFV.

    Last, the name Alkhurma virus, not Alkhumra, was proposed by Dr AM Zaki who discovered the virus.(2) The first case was diagnosed in a patient who became sick after he slaughtered a sheep imported from the city of Alkhurma (Al Taief area), hence the name of the virus. Later, several cases occurred in patients living in the city of Alkumra, and this could explain the confusion in the name. Since, Alkhurma virus can cause hemorrhagic fever, we recently proposed Alkhurma hemorrhagic fever virus (acronym AHFV) as a genotype of the species Kyasanur forest disease virus. This proposal is currently being studied by the Flavivirus section within the International Committee for Taxonomy of Viruses. So far, a total of 12 scientific papers archived in PubMed have been related to this virus: Of these, nine adopted the name Alkhurma. Four of them include authors from Saudi Arabia, two of which were working for the Ministry of Health (9).


    1. Madani TA, Albarrak AM, Alhazmi MA, Alazraqui TA, Althaqafi AO, Ishaq AH. Steady improvement of infection control services in six community hospitals in Makkah following annual audits during Hajj for four consecutive years. BMC Infect Dis 2006;6:135.

    2. Charrel RN, Zaki AM, de Lamballerie X. Human cases of hemorrhagic fever in Saudi Arabia due to a newly discovered flavivirus, Alkhurma hemorrhagic fever virus. In: Growing infections in Asia, ed. Essex M and Lu Y. Springer Verlag Publishers. In press

    3. Charrel RN, Zaki AM, Fakeeh M, Yousef AI, de Chesse R, Attoui H, et al. Low diversity of Alkhurma hemorrhagic fever virus, Saudi Arabia, 1994–1999. Emerg Infect Dis 2005;11: 683–8.

    4. Memish ZA, Balkhy HH, Francis C, Cummingham G, Hajeer AH, Almuneej MA. Akhumra haemorrhagic fever: Case report and infection control details. Br J Biomed Sci 2005;62:37–9.

    5. Zaki AM. Isolation of a flavivirus related to the tick-borne encephalitis complex from human cases in Saudi Arabia. Trans R Soc Trop Med Hyg 1997;91:179–81.

    6. Charrel RN, Zaki AM, Attoui H, Fakeeh M, Billoir F, Yousef AI, et al. Complete coding sequence of the Alkhurma virus, a tick-borne flavivirus causing severe hemorrhagic fever in humans in Saudi Arabia. Biochem Biophys Res Commun 2001; 287:455–61.

    7. Charrel RN, Attoui H, Butenko AM, Clegg JC, Denbel V, Frolova TV, et al. Tick-borne virus diseases of human interest in Europe. Clin Microbiol Infect 2004;10:1040–55.

    8. Gresikova M, Sekeyova M, Stupalova S, Necas S. Sheep milkborne epidemic of tick-borne encephalitis in Slovakia. Intervirology 1975;5:57–61.

    9. Shoemaker T, Boulianne C, Vincent MJ, Pezzanite L, Al-Qahtami MM, Al-Marzon Y, et al. Genetic analysis of viruses associated with emergence of rift valley fever in Saudi Arabia and Yemen, 2000–01. Emerg Infect Dis 2002;8:1415–20.

    X. de Lamballerie a

    R.N. Charrel a*

    a Unité des Virus Emergents, Université de la Méditerranée, 27 blvd Jean Moulin, 13005 Marseille, France

    • Corresponding author. Tel.: 33 4 91 32 45 53; fax: 33 4 9132 44 95

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    Competing interests

    no competing interest