Crimean Congo Hemorrhagic Fever (CCHF) is a highly fatal viral zoonotic disease caused by a tickborne virus (Nairovirus). It is primarily transmitted to humans either by the bite of the Hyaloma ticks or by direct contact with blood or tissues, secretions, organs or other bodily fluids of an infected animal during and immediately after slaughter. Human to human transmission can also occur resulting from close contact with bodily fluids of infected persons. Hospital acquired infections can also occur due to improper sterilization of medical equipment, reuse of needles and contamination of medical supplies. The hosts of the CCHF virus include a wide range of wild and domestic animals such as cattle, sheep and goats. A case with sudden onset of high grade fever over 38.5OC for more than 72 hours and less than 10 days, especially in CCHF endemic area and among those in contact with sheep or other livestock (shepherds, butchers, and animal handlers including exposed family members) is defined as CCHF. The fever is usually associated with headache and muscle pain and does not respond to antibiotic or anti malarial treatment. Other signs and symptoms include malaise, weakness, irritability, and marked anorexia. There may be bleeding from gums, nose, lungs, uterus and intestine, but only in serious cases associated with severe liver damage. A single case of CCHF is considered by DEWS Plus as an outbreak and is investigated. The number of outbreaks of CCHF shows significant increase in Afghanistan. Similarly the number of deaths and provinces has tripled in 2016 (18 deaths, 24 provinces) compared to 2013 (6 deaths, 8 provinces). The data since 2007 shows that the number of CCHF cases and outbreaks has increased from 2 provinces (Herat and Helmand) to other 26 provinces. The sudden increase of CCHF cases also typically corresponded with the post exposure animal sacrifice during Eid Al Adha. Outbreaks of CCHF are a major public health concern n Afghanistan. Though the majority of the cases are reported from Herat province, the spread of the disease to 24 provinces is concerning. This pattern in the spread of the disease is a potential public health emergency of international concern (PHEIC). Risk of infection to health staff is high and the importance of IPC in hospitals also needs to be emphasized. Transboundary and internal movement of livestock need to be continuously monitored along with effective use of appropriate acaricide to reduce the tick population.

1. Crimean-Congo Hemorrhagic Fever
(CCHF)
Wazhma Hakimi
Doctor of Medicine (MD), Master of Public Health (MPH), Master
of Science in International Health (MScIH)

5. 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Suspected 4 66 36 19 22 40 36 57 113 183 105
Deaths 0 9 0 0 0 6 4 2 20 18 26
Lab Confirmed 1 15 12 4 2 9 11 18 34 50 28
0
20
40
60
80
100
120
140
160
180
200
Number
CCHF In Afghanistan 2007-2017

9. Number of CCHF cases by month from 2015-2017
0
10
20
30
40
50
60
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2015 Y
2016 Y
2017 Y

10. Cases and deaths in Afghanistan

11. Distribution of cases by occupation
23%
18%
22%
16%
1%
20%
0%
5%
10%
15%
20%
25%
Shepherd Butucher Hous wife Farmar health staff others
Occupationby%
Occupation

12. CCHF Cases distribution by Age
1
31 30
12
14
17
0
5
10
15
20
25
30
35
<10 11-20Y 21-30 31-40 41-50 >50

14. Endemic in many regions (Al-Abri SS et al., 2017):
• Africa:
• (Democratic Republic of Congo, Uganda, Mauritania, Nigeria, South
Africa, Senegal, Sudan)
• Asia:
• (China, Kazakhstan, Tajikistan, Uzbekistan, Afghanistan, Pakistan, India)
• Eastern and Southern Europe:
• (Russia, Bulgaria, Kosovo, Turkey, Greece, Spain)
• Middle East:
• (Iraq, Iran, Kuwait, Saudi Arabia, Oman, United Arab Emirates (UAE)
• Recently, rapid increase in WHO EMR
CCHF is known by different names:
• Khungribta (Blood taking)
• Khunymuny(Nose bleeding)
• Karakhalak (Black death)
• Asian Ebola
Country years
Crimea 1944
Turkmenistan 1946
Yogosalavia 1949
Congo 1956
Iran 1970
Bulgaria 1973
Pakistan 1976
Queet 1979
Saudi Arabia 1990
Afghanistan 1997
India 2011

15. What is Crimean-Congo Hemorrhagic Fever (CCHF)?
• highly severe and fatal
• Viral
• Hemorrhagic
• zoonotic disease
• caused by a tickborne virus (Nairovirus)
• CFR=2-50%
• The hosts of the CCHF virus include
• a wide range of wild and domestic animals
such as:
cattle, sheep, goats and camels

16. How is CCHF transmitted?
• The Hyalomma tick: reservoir and the vector for CCHFV.
• It is primarily transmitted to humans by:
• the bite of these ticks
• contact with infected ticks (specially squeezing it on the skin)
• direct contact with skin, blood or tissues, secretions, organs or other bodily fluids of
an infected animal
• During slaughtering or a short period after slaughter
• Human-to-human transmission
• dead body of an infected animal or human
• Documented hospital-acquired infections and spread due to:
• improper sterilization of medical equipment,
• reuse of needles and contamination of medical supplies.
• When a person is infected, those who are in contact with this person in the family
or community can also be infected.
• Birds: carrier of the tick, but they are not affected except ostrich.

17. How CCHF is transmitted?
• Virus can stay in tick till 2 years
• Lays 2000-8000 eggs each time and reproduces thousands other
infected ones especially in increased temperature
• does not cause any disease in animals
• Hosts/domestic animals have viremia for around one week after
becoming infected.
• Meat itself is not the source of infection because the virus is
inactivated after few hours by post-slaughter acidification of the
tissue;
• CCHF virus does not survive cooking because it is sensitive to the
heat and is inactivated at 560C within 30 minutes.

18. Who is most at risk of getting CCHF?
• those in contact with livestock:
• Farmers
• Veterinarians
• agricultural workers
• slaughterhouse workers
• Shepherds
• Butchers
• animal handlers including exposed family members especially housewives in
endemic areas.
• Healthcare workers in endemic areas
• Individuals and international travelers with contact to livestock in
endemic regions

19. What are signs and symptoms of CCHF?
Most of the infected individuals (80% or less) are without signs and
symptoms.
Classic clinical manifestations of CCHF has four stages:
1. Incubation period
2. Pre-hemorrhagic stage
3. Hemorrhagic stage
4. Convalescence period

20. Incubation period:
• The incubation period after the bite of the tick:
• at least 1-3 days
• maximum 9 days
• The incubation period after contact with infected tissue and blood:
• usually 5-6 days
• maximum 13 days

21. Pre-hemorrhagic stage:
• The onset of signs and symptoms:
• Sudden
• lasts for 1-7 days (average 3 days)
• severe headache
• high fever
• Dizziness
• myalgia/muscle pain
• neck pain and stiffness
• back and joint pain
• red and painful eyes, and photophobia.
• nausea, vomiting, sore throat, conjunctivitis at the
beginning of the disease which is sometimes
associated with diarrhea, generalized abdominal
pain and decreased appetite.
• In severe cases:
• changes in mood and sensory perception and may
become confused and aggressive
• After two to four days;
• the agitation may be replaced by sleepiness, depression
• abdominal pain may localize to the right upper
quadrant, with detectable hepatomegaly.
• Fever is continual but it can be remittent.
• The fever lasts for 3-16 days.
• Edema and redness of face, neck and chest
• red throat and pharynx
• petechiae (red spots) on the soft and hard palate
• thrombocytopenia and leukopenia
• decrease in heart rate and blood pressure

22. Hemorrhagic stage:
• short stage
• happens quickly
• Starts within the 3rd to 5th day of the
disease
• lasts from 1 to 10 days (average 4 days)
• or the patient dies in this stage
• Cardiac arrest, massive hemorrhage
• Hemorrhage ranging from:
• petechiae to ecchymosis and hematoma
• in mucus and skin
• on the upper part of the body
• at injection sites
• the areas under pressure
• applying site of Tourniquet
• bleeding from:
• Gums and Nose
• uterus and intestine (hematemesis and
melena)
• conjunctival and ear hemorrhage
• Sometimes bloody sputum
• respiratory problems
• splenomegaly and hepatomegaly
• Hematuria and proteinuria is common.
• Other clinical signs:
• Tachycardia
• Lymphadenopathy
• evidence of hepatitis
• severely ill
• Liver damage, hepatorenal and pulmonary
failure after the fifth day of illness.

23. Convalescence period:
• From the 10th day
• skin lesions start disappearing,
• recovery.
• discharged within the 3rd to 6th week of the disease when blood indicators
and urine tests become normal.
• it takes long time

24. How is CCHF diagnosed?
• Isolation of CCHFV from the blood in acute phase (within the first 8
days of the disease)
• About 6 days after the onset of the disease it is possible to isolate
IgG and IgM in the serum by ELISA.
• According to criteria for clinical diagnosis of CCHF by Swanepoel et
al.:
• a total score of 12 points or more constitutes an indication for treating a
patient as a case of CCHF.
• So, the clinical diagnosis of CCHF should be based on below criteria:

26. How is CCHF treated?
Case definition for CCHF: A case with sudden onset of high-grade fever over
38.5°C for more than 72 hours and less than 10 days, especially in CCHF
endemic area and among those who are at risk is defined as CCHF.
Immediately after diagnosing a suspected case of CCHF, treatment should
be started.
• Supportive treatment:
• careful attention to fluid balance and correction of electrolyte abnormalities,
• treatment of disseminated intravascular coagulation (DIC),
• oxygenation and hemodynamic support,
• appropriate treatment of secondary infections.
• Vital signs and Hematocrit
• Mgt of Low level of hemoglobin (Hb) >> by blood transfusion
• severe thrombocytopenia and signs of active bleeding >> platelet transfusion
should be done

27. To summarize, the following basic interventions, when used early, can
increase the chances of survival.
• Providing fluids and electrolytes
• Maintaining oxygen status and blood pressure
• Treating other infections if they occur
Antiviral treatment:
• Ribavirin- oral and IV
• most effective if given in the first 6 days of illness
• The duration of treatment with ribavirin is 10 days

28. Prevention and Control
• Notifiable within the framework of IHR 2005,
• Public Health Emergency of International Concern
• Zoonotic Committee to prepare prevention and control plan , Joint Response
• emergency preparedness and response committee
• Strengthening Outbreak Response through Surveillance
• Immediately reporting of suspected case and + lab reports
• Staring investigation within 48 hours
• Education of health workers to diagnose, report, and mgt of cases according to national protocol
• Medical supplies including ribavirin and blood sample collection container
• Advocacy and update of higher authorities
• Strong coordination with related organizations especially Veterinary department and political
authorities at national and provincial level.
• Safe burial practices
• Healthcare workers exposed
• At high risk---------blood sample, prophylactic Ribavirin
• At low risk(e.g. contact with patient environment) -----FU for 14 days, monitoring temp. and platelet/WBCs
counts ------Ribavirin

30. National Strategy for the Prevention and
Control of Zoonotic Diseases:
• Sustaining the current surveillance systems
• and shifting towards more active surveillance and electronic
information sharing
• Improving the current joint response mechanism
• Improving multi-sectoral cooperation at the National level
• Devising a compensation plan to encourage reporting of disease
from farmers

31. • Investigation of contacts and source of infection:
• Identify all close contacts in the three weeks after the onset of illness
• record of body temperature twice a day for 3 weeks after last exposure.
• If temperature is greater than 100.4°F (38.3°C), they should be referred to
the hospital immediately and should be isolated.
• Organize awareness-raising campaigns
• Health education and behavioral change
• Tick control with acaricides
• Quarantining animals before they enter slaughterhouses or routinely
treat animals with pesticides two weeks prior to slaughter
• Persons who work with livestock or other animals in the endemic
areas can take practical measures to protect themselves.
• repellents on exposed skin
• soaking clothes with permethrin and spraying it on shoes

33. Challenges:
• No accurate data on the burden of the disease due to different surveillance
systems in different countries.
• Current knowledge gaps that are hindering effective control interventions
• Lack of research
• Lack of awareness regarding CCHF control and preventive measures
• Lack of Isolation wards in provincial Hospitals
• Lack of trained health workers in Isolation wards on mgt and reporting
• No hazard pay
• Lack of resources for the treatment and prevention
• Lack of preventive and control measures by the ministry of public health
• Lab Capacity Building
• Delay in referral system by private sector
• No Strategy for the elimination of the ticks in endemic areas
• No quarantine sites for animals in borders before they enter the country

34. • Inadequate assessment of animals before slaughtering
• No standard slaughterhouse
• The closeness of the living place of humans and animals
• Movement of animals
• Inadequate facilities for spraying animals
• Unsafe animal carcasses from slaughterhouse to butchers and
restaurant.
• Insecurity a problem for investigation of each case
• Lack of funds for IEC materials
• Establishing workshops at provincial level at inappropriate times

36. CCHF Case investigation in Herat regional hospital 19th Jun 2017

41. References:
• Stuart, M. C., Kouimtzi, M., & Hill, S. R. (Eds.). (2009). WHO model formulary 2008. World Health Organization. Available at:
http://www.who.int/selection_medicines/list/WMF2008.pdf?ua=1
• APPLICATION FOR INCLUSION OF RIBAVIRIN IN THE WHO MODEL LIST OF ESSENTIAL MEDICINES. (07 Nov. 2006). Retrieved from:
http://archives.who.int/eml/expcom/expcom15/applications/newmed/ribaravin/ribavirin.pdf
• Crimean-CongoHemorrhagic Fever. (9, May, 2014). Centers for Disease Control and Prevention (CDC). Retrieved from: https://www.cdc.gov/vhf/crimeancongo/index.html
• Treatment of CCHF. (26, April, 2017). Retrieved from: https://www.cdc.gov/vhf/crimean-congo/treatment/index.html
• WHO/Factsheet No. 208: Crimean-CongoHaemorrhagic Fever. (Revised January 2013). Retrieved from: http://www.who.int/mediacentre/factsheets/fs208/en/
• WHO/Clinical Management of Patients with Viral Haemorrhagic Fever: A Pocket Guide for the Front - line Health Worker. (13, April, 2014). Retrieved from:
https://www.unicef.org/cbsc/files/VHF_pocket_book_Guinea-2014.pdf
• Communicable Disease Surveillance and Response. (May, 2017). ATLAS of Diseases under Surveillance in Afghanistan – 2016. 1st edn. Afghansitan: WHO in collaboration with
MoPH, Afghanistan.
• WHO. (2017). Disease Early Warning System (DEWS) Annual Report 2016.
• World Health Organization. Operational guidelines for CCHF outbreak response in Afghanistan.
• Dhaduk, K. M., Gandha, K. M., Unadkat, S. V., Makwana, N. R., Parmar, D. V., & Yadav, S. (2013). Outbreak investigationand intervention measures following viral hemorrhagic
fever in rural Kutch (Gujarat). International Journal of Health & Allied Sciences, 2(3), 189. Available at:
http://www.xa.yimg.com/kq/groups/18156219/1652059995/name/CCHF_criteria_for_clinical_diagnosis.pdf. [Last accessed on 2013 Jan 29].
• Swanepoel R, Gill DE, Shepherd AJ, Leman PA, Mynhardt JH, Harvey S: The clinical pathology of Crimean-Congo hemorrhagic fever. Rev Infect Dis. 1989, 11 (Suppl 4): S794-800
• Prevention of Crimean-CongoHaemorrhagic (CCHF) Fever (Human and Animals) in Pakistan. (October, 2010). Retrieved from:
http://www.nih.org.pk/files/Guidelines/Prevention%20of%20Crimean-Congo%20Haemorrhagic%20(CCHF)%20Fever%20(Human%20and%20Animals)%20in%20Pakistan.pdf
• Chinikar, S., Ghiasi, S. M., Hewson, R., Moradi, M., & Haeri, A. (2010). Crimean-Congo hemorrhagic fever in Iran and neighboring countries. Journal of Clinical Virology, 47, 110-
114.
• Al-Abri, S. S., Al Abaidani, I., Fazlalipour, M., Mostafavi, E., Leblebicioglu, H., Pshenichnaya, N., ... & Nguyen, T. M. N. (2017). Current status of Crimean-Congohaemorrhagic
fever in the World Health Organization Eastern Mediterranean Region: issues, challenges, and future directions. International Journal of Infectious Diseases, 58, 82-89.

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