Home | Supplements | Volume 40 | This supplement | Article number 3

Case study

Emergence of a febrile illness of unknown causes among the population and visitors of Upper Egypt

Emergence of a febrile illness of unknown causes among the population and visitors of Upper Egypt

Maged Mounir Ibrahim1, Afreenish Hassan Amir2, Ricardo Strauss3, Muhammad Asif Syed4, Eva Mertens3,5,&


1Central Laboratory for Evaluation of Veterinary Biologics (CLEVB), Agriculture Research Center (ARC), Cairo, Egypt, 2National Institutes of Health, Islamabad, Pakistan, 3Bernhard Nocht Institute for Tropical Medicine, Department of Infectious Disease Epidemiology, Bernhard-Nocht-Strasse 74, 20359 Hamburg, Germany, 4Field Epidemiology Laboratory Training Program (FELTP) Pakistan, Islamabad, Pakistan, 5Global Partnership Initiated Biosecurity Academia for Controlling Health Threats (GIBACHT), Hamburg, Germany



&Corresponding author
Eva Mertens, Bernhard Nocht Institute for Tropical Medicine, Department of Infectious Disease Epidemiology, Bernhard-Nocht-Strasse 74, 20359 Hamburg, Germany




This is a fictional case study for training that encourages participants to interact and apply theory into practice. A febrile illness of unknown cause that occurred in Upper Egypt in 2002 was chosen for the events. The location of Aswan was selected to define the climate, topography, and location with the characteristics that support the events. Data obtained from applied research work in Egypt was included. The case study deals with the incidence of severe cases of fever of unknown origin accompanied by neurological and intestinal symptoms, as well as a high percentage of deaths. Most of the symptoms appear in people with direct contact with farm animals especially equines and birds, or those who were near waterways, either tourism workers or tourists. Most of the infected cases or deaths have accumulated in Aswan and some in the neighbouring governorates. This case study focusses on the steps taken during an outbreak investigation, and deals with investigative challenges as well as concepts of biosafety and biosecurity.



How to use this case study    Down

General instructions: this is a fictional case study and some of its real data was obtained from an applied research work and investigations in Egypt [1]. The details of the original research work have been modified to enhance learning objectives and support the instructional goal. Fifteen (15) participants should be matched to two facilitators in a training room, preferably at a round table. Each participant should be issued a copy of the case study prior to its implementation. The facilitator guide remains with the facilitator. The facilitator introduces the learning objectives of the case study and materials that participants should have at hand before starting the case study. Participants take turns to read the case scenario and the questions or tasks that follow. The participants then discuss and attempt to provide the answer to the question. The facilitator should stimulate participants to discuss and arrive at the correct responses.

Audience: health care providers, epidemiologists, clinicians, undergraduate/ postgraduate students and public health professionals.

Prerequisites: before using this case study, participants should have received lectures or other instruction in outbreak investigation.

Materials: note book, pen, flipcharts, chart papers, markers, calculators and laptops.

Level of training and associated public health activity: Novice - Outbreak investigation

Time required: the expected time for the case study is about 3 hours

Language: English



Case study material Up    Down

  • Download the case study student guide
  • Request the case study facilitator guide



Competing interests Up    Down

The authors declare no competing interests.



Acknowledgement Up    Down

The authors wish to acknowledge the Global Partnership Initiated Academia for Controlling Health Threats (GIBACHT) and their funding body, the German Federal Foreign Office, for their support in developing this case study.



References Up    Down

  1. Sayed-Ahmed M. Incidence history of west Nile virus in Africa and middle east, with an emphasis on Egypt: a review. J Dairy Vet Anim Res. 2016;3(3):101-104 G. PubMed | Google Scholar

  2. Soliman A, Mohareb E, Salman D, Saad M, Salama S, Fayez C et al. Studies on West Nile virus infection in Egypt. J Infect Public Health. 2010;3(2):54-9. PubMed | Google Scholar

  3. Sejvar JJ. Clinical manifestations and outcomes of West Nile virus infection. Viruses. 2014 Feb 6;6(2):606-23. PubMed | Google Scholar

  4. The Directors of WHO Collaborating Centers for Biosafety and other advisers. Guidance on regulation for the transport of infectious substance 2015 - 2016. Applicable as from 1 January 2015. WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland. PubMed | Google Scholar

  5. Roehrig JT, Nash D, Maldin B, Labowitz A, Martin DA, Lanciotti RS et al. Persistence of virus-reactive serum immunoglobulin m antibody in confirmed west nile virus encephalitis cases. Emerg Infect Dis. 2003 Mar;9(3):376-9. PubMed | Google Scholar

  6. Caribbean Public Health Agency. State of Public Health. 2019. Healthy Ageing in the Caribbean. Port of Spain, Trinidad, and Tobago: CARPHA; 2020.

  7. Ahmadnejad F, Otarod V, Fallah MH, Lowenski S, Sedighi-Moghaddam R, Zavareh A et al. Spread of West Nile virus in Iran: a cross-sectional serosurvey in equines, 2008-2009. Epidemiol Infect. 2011 Oct;139(10):1587-93. PubMed | Google Scholar

  8. Faulde MK, Spiesberger M, Abbas B. Sentinel site-enhanced near-real time surveillance documenting West Nile virus circulation in two Culex mosquito species indicating different transmission characteristics, Djibouti City, Djibouti. J Egypt Soc Parasitol. 2012 Aug;42(2):461-74. PubMed | Google Scholar

  9. Andreadis TG, Anderson JF, Vossbrinck CR. Mosquito surveillance for West Nile virus in Connecticut, 2000: isolation from Culex pipiens, Cx. restuans, Cx. salinarius, and Culiseta melanura. Emerg Infect Dis. Jul-Aug 2001;7(4):670-4. PubMed | Google Scholar

  10. Selim A, Abdelhady A. The first detection of anti-West Nile virus antibody in domestic ruminants in Egypt. Trop Anim Health Prod. 2020 Nov;52(6):3147-3151 Epub 2020 Jun 25. PubMed | Google Scholar

  11. Steinman A, Banet-Noach C, Tal S, Levi O, Simanov L, Perk S et al. West Nile virus infection in crocodiles. Emerg Infect Dis. 2003 Jul;9(7):887-9. PubMed | Google Scholar

  12. Harrington, Rebecca A. "Case fatality rate". Encyclopedia Britannica. 5 May 2020. Accessed on 05 April 2021.

  13. Dicker R, Coronado F, Koo D, Parrish RG. Principles of Epidemiology in Public Health Practice, 2nd edition.CDC, Atlanta, USA. 1992.

  14. Dwyer DM, Groves C. Outbreak epidemiology. In: Nelson KE, Williams CM. Infectious disease epidemiology: theory and practice. Gaithersburg, USA. Aspen Publishers. 2001.

  15. Weber DJ, Menajovsky LB, Wenzel R. Investigation of outbreaks. In: Thomas JC, Weber DJ. Epidemiologic methods for the study of infectious diseases. New York, USA. Oxford University Press. 2001.

  16. Bender JB, Shulman SA; Animals in Public Contact subcommittee; National Association of State Public Health Veterinarians. Reports of zoonotic disease outbreaks associated with animal exhibits and availability of recommendations for preventing zoonotic disease transmission from animals to people in such settings. J Am Vet Med Assoc. 2004 Apr 1;224(7):1105-9. PubMed | Google Scholar

  17. Eldridge BF, Scott TX, Day JF, Tabachnick W. Chapter 11: Arbovirus Diseases. In: Medical Entomology (pp.415-460). Revised Edition. 2004. Kluwer Academic Publishers.

  18. Depoortere E, Kavle J, Keus K, Zeller H, Murri S, Legros D. Outbreak of West Nile virus causing severe neurological involvement in children, Nuba Mountains, Sudan, 2002. Trop Med Int Health. 2004 Jun;9(6):730-6. PubMed | Google Scholar

  19. Kapoor H, Signs K, Somsel P, Downes FP, Clark PA, Massey JP. Persistence of West Nile Virus (WNV) IgM antibodies in cerebrospinal fluid from patients with CNS disease. J Clin Virol. 2004 Dec;31(4):289-91. PubMed | Google Scholar

  20. Martin DA, Muth DA, Brown T, Johnson AJ, Karabatsos N, Roehrig JT. Standardization of immunoglobulin M capture enzyme-linked immunosorbent assays for routine diagnosis of arboviral infections. J Clin Microbiol. 2000 May;38(5):1823-6. PubMed | Google Scholar

  21. Bhatnagar J, Guarner J, Paddock CD, Shieh WJ, Lanciotti RS, Marfin AA et al. Detection of West Nile virus in formalin-fixed, paraffin-embedded human tissues by RT-PCR: a useful adjunct to conventional tissue-based diagnostic methods. J Clin Virol. 2007 Feb;38(2):106-11. PubMed | Google Scholar

  22. Youssef SR, Eissa DG, Abo-Shady RA, Aly Fouad NT, Kattab DK, Fathey H et al. Seroprevalence of anti-WNV IgG antibodies and WNV-RNA in Egyptian blood donors. J Med Virol. 2017 Aug;89(8):1323-1329. PubMed | Google Scholar

  23. World Health Organization, WHO Guidance for the use of Annex 2 of the International Health Regulations 2005, Decision instrument for the assessment and notification of events that may constitute a public health emergency of international concern. 2010. Google Scholar

  24. Beck C, Jimenez-Clavero MA, Leblond A, Durand B, Nowotny N, Leparc-Goffart I et al. Flaviviruses in Europe: complex circulation patterns and their consequences for the diagnosis and control of West Nile disease. Int J Environ Res Public Health. 2017 Aug;89(8):1323-1329. PubMed | Google Scholar

  25. Vest DJ, Cohen ND, Berezowski CJ, Morehead JP, Blodgett GP, Blanchard TL. Evaluation of administration of West Nile virus vaccine to pregnant broodmares. J Am Vet Med Assoc. 2004 Dec 15;225(12):1894-7. PubMed | Google Scholar

  26. Chancey C, Grinev A, Volkova E, Rios M. The global ecology and epidemiology of West Nile virus. Biomed Res Int. 2015;2015:376230. PubMed | Google Scholar

  27. Turell MJ, Morrill JC, Rossi CA, Gad AM, Cope SE, Clements TL et al. Isolation of west nile and sindbis viruses from mosquitoes collected in the Nile Valley of Egypt during an outbreak of Rift Valley fever. J Med Entomol. 2002 Jan;39(1):248-50. PubMed | Google Scholar

  28. Orshan L, Bin H, Schnur H, Kaufman A, Valinsky A, Shulman L et al. Mosquito vectors of West Nile Fever in Israel. J Med Entomol. 2008 Sep;45(5):939-47. PubMed | Google Scholar

  29. Campbell GL, Marfin AA, Lanciotti RS, Gubler DJ. West Nile virus. Lancet Infect Dis. 2002 Sep;2(9):519-29. PubMed | Google Scholar

  30. Malkinson M, Banet C. The role of birds in the ecology of West Nile virus in Europe and Africa. Curr Top Microbiol Immunol. 2002;267:309-22. PubMed | Google Scholar