in october 2008 , an outbreak of hemorrhagic fever was reported in al - fulah , kordufan , sudan . the index patient was a 60-year - old man who had worked as a butcher . the source of his infection was suspected to have been tissues and blood of an infected animal , although follow - up investigation was unable to precisely determine the source . he was admitted to a rural hospital with an acute febrile hemorrhagic illness after 3 days of high fever , chills , and headache . he had epistaxis , black bloody vomitus , and diarrhea on the last 2 days of his illness . illness developed in a male nurse who had provided care to the index patient 6 days after the index patient had been admitted to the hospital and in the chief male nurse a few days after that . the index patient s sister was also considered to have a suspected case ; she had sought care at the hospital after a heavy menstrual period that progressed to massive vaginal bleeding . the midwife who performed the gynecologic examination later became ill with high fever , vomiting of blood , and bloody diarrhea . as is tradition and social obligation in rural hospitals in this region , 2 relatives of the index patient had alternated caring for him ( e.g. , dressing him , changing his mattresses and bed sheets , nursing , and sleeping beside him ) while he was in the hospital , and both acquired the infection ( rapid onset of fever , headache , nausea , vomiting of blood , and bloody diarrhea ) . no details were available for 3 other patients with hemorrhagic fever associated with the hospital . of these 10 patients , 9 were admitted to a rural hospital in al - fulah , where 6 continued to bleed , subsequently became comatose , and died . each of these 3 persons had a course of hemorrhagic disease and death that was compatible with cchf ; they had not been admitted to the hospital and could not be traced because of poor security conditions in the region . nosocomial transmission of the virus was likely the result of lack of personal protection for the hospital staff and the attending relatives , as has been often noted during previous outbreaks ( 6 ) . of the patients for whom serum samples were available , 8 had evidence of acute cchfv infection . direct immunofluorescence assay detected no antibodies to cchfv in any of the serum samples ; however , all samples had been collected on days 13 of illness . virus rna extracted from each of the samples by qiaamp ( qiagen gmbh , hilden , germany ) was positive according to reverse transcription the rna was then used in rt - pcrs to amplify the entire virus s segment for complete sequencing as described ( 8) . the full - length s segment nucleotide sequence of the strains from sudan was 1,673 nt long , and the 8 viral sequences were identical with the exception of that from patient 4 ( genbank accession nos . gq8623712 ) . a maximum - likelihood phylogenetic analysis of the s segment sequences placed the viruses from sudan in group iii ( 8) , which is composed exclusively of viruses of african origin , including south africa , mauritania , and nigeria ( figure ) . phylogenetic relationship of crimean - congo hemorrhagic fever virus ( cchfv ) full - length small ( s ) segments . garli ( v0.96b8 ) ( 9 ) with default settings was used to generate a maximum - likelihood tree with bootstrap support values from 1,000 replicates . from the analysis , virus strains from sudan patients 1 , 2 , 3 , 6 , 7 , 8 , and 9 ( genbank accession no . gq862371 ) were identical , and the virus sequence from patient 4 ( genbank accession no . each strain is listed by its location , strain name , and year of isolation , when available . laboratory confirmation of 8 cases of cchf demonstrates the presence of this disease in sudan . genetic analysis of the viruses showed that the strain involved was similar to strains found in south africa , mauritania , and nigeria . detailed analysis of virus outbreaks is often limited by the lack of appropriate high - containment facilities required for virus isolation . however , appropriately sampled and stored acute - phase serum samples can have high titers of the virus , which enable extraction of virus rna and genome sequencing studies without prior amplification of the virus in cell culture . in this study , serum specimens from 8 patients who died were positive for cchfv by rt - pcr . lack of virus - specific antibodies 13 days after onset of illness can be explained by the severity and rapid course of the disease , which does not allow sufficient time for antibody production . virus - specific antibodies are , however , generally seen later in the course of illness and in persons who survive the infection . . indirect evidence for cchfv in animals in sudan came from finding cchfv - specific antibodies in animals imported from sudan : camels in egypt ( 12 ) and sheep and goats in saudi arabia ( 13 ) . the finding that the al - fulah outbreak was caused by a cchfv strain from genetic group iii illustrates how different virus strains and lineages can move with livestock transport or possibly bird migrations . the genome plasticity of the virus is surprisingly high for an arthropod - borne virus . this genetic diversity appears to be the result of not only accumulation of mutations but also of frequent rna segment reassortment and even rna recombination ( 814,15 , ) . clearly , this cchfv is present in sudan , and physicians should consider cchf as a diagnosis for hemorrhagic fever cases in the region . in addition , efforts to provide appropriate personal protective supplies and training to medical staff in rural areas should be increased to help minimize risk for caregivers .
to confirm the presence of crimean - congo hemorrhagic fever in sudan , we tested serum of 8 patients with hemorrhagic fever in a rural hospital in 2008 . reverse transcription  pcr identified crimean - congo hemorrhagic fever virus . 
 its identification as group iii lineage indicated links to virus strains from south africa , mauritania , and nigeria .