Crimean-Congo hemorrhagic fever is an acute disease caused by a virus transmitted by ticks that occurs in 38 countries including Iraq, Afghanistan, and Pakistan. It is most common in those working with livestock like herders, workers, and slaughterhouse employees. The virus is found in ticks, hedgehogs, horses, and rodents. Symptoms include fever, vomiting, rash, and hemorrhaging with a fatality rate of 30-50%. There is no vaccine but supportive care and ribavirin are used for treatment. Reducing tick bites and safe handling of animals are key prevention strategies.

1. S H A K E R A S A D I Q G I L L
Crimean-congo hemorrhagic
fever

2. Definition
 An acute disease caused by arbovirus that can be
transmitted to humans by ticks.
 First described by 1944 in crimean peninsula
 Viral etiology was confirmed in 1945

3. Etiology
 CCHF belongs to family Bunyaviridae genus
Nairovirus (from Nairobi sheep disease virus)

4. Occurrence
 Human CCHF is known to occur in 38 countries
including
 Iraq
 Afghanistan
 Pakistan

5.  In areas of endemicity infection with CCHF found in
human and domestic animals more frequently in
cattle than in sheep and goats.

6. Risk of Exposure
 Animal herders, livestock workers, and
slaughterhouse workers in endemic areas are at risk
of CCHF.
 Healthcare workers in endemic areas handling blood
and body fluids.
 Individuals and international travellers with contact
to livestock in endemic regions may also be exposed.

7. Reservoir of infection
 Hedgehogs
 Horses
 Mouse like rodents act as reservoir

8. Hedgehogs

9. Vectors
 Ticks act as reservoir
 CCHF has been isolated from more than 30 species
of ticks including predominately Hyalomma but also
Ixodes species

10. Ticks

11.  Human infection occur in rural areas with livestock,
slaughter houses and dairy cattle as the source of
epidemic
 In Afghanistan and UAE camels introduce the CCHF
virus

12. Transmission
 Contact with ticks
 Infected livestock
 Tick sucking on a cow bruised with hand, virus can
be transmitted
 Slaughtering of animals
 Castration
 Branding of animals

13.  Support in birth
 Nosocomial infections are frequent
 Occur in patient care takers
 Aerosol transmission
 Used as biological weapon for bioterrorism

14. Clinical manifestations
 Incubation period after tick bite is 1-3 days
 Depending upon the dose IP may up to 9 days
following nosocomial exposure to viremic
blood,tissues and excreta
 Fever
 Shivering
 Maliase

15.  Irritability
 Head-limb and backaches.
 Anorexia
 Abdominal pain and nausea
 Vomiting is common
 Fever last for 5-12 days but biphasic courses are seen

16.  Skin on face and neck is red and swollen
 Conjunctiva and mucous membranes are congested
and edematous
 Petechial bleeding on the skin of entire body
 Bleeding on mucosal membranes
 Urogenital bleeding
 Case fatality is 30 -50 days

17.  Patients die with hemorrhagic shock and secondary
infections.

18. Diagnosis
 Diagnostic tests should be performed in BSL 4
 PCR
 RT-PCR
 Testing for virus specific IgM antibodies
 ELISA
 Serum neutralization

19. Differential diagnosis
 Typhoid fever
 Malaria
 Yellow fever
 Dengue

20. Therapy
 Treatment for CCHF is primarily supportive.
 Care should include careful attention to fluid balance
and correction of electrolyte abnormalities,
oxygenation and appropriate treatment of secondary
infections.
 Intensive care should be given with protective
clothing's
 Vital function must be controlled

21.  Packed red cells, platelets, clotting factors and
albumin are required for the treatment of
hemorrhagic shock.
 Ribavirin blocks viral replication can be used.
 Transport of patient with hemorrhagic fever to the
hospital in isolation quarters is not recommended.
 In critical stage the patients be attended by
experienced personal.

22. Prophylaxis
 Inactivated virus vaccine from mouse brain was
prepared in Russia
 No modern vaccine is available
 Use gloves and protective clothing while handling
infected patients and cattle
 Nosocomial infections should be prevented
 Safe handing of infected material

23.  Specimen should be inactivated before removal from
isolation ward
 Addition of detergent will reduce the virus titer
 The most dangerous manipulation is running
specimen in the centrifuge
 Infected needles and knives should be avoided

24.  Agricultural workers and others working with
animals should use insect repellent on exposed skin
and clothing.
 Insect repellents containing DEET (N, N-diethyl-m-
toluamide) are the most effective in warding off
ticks.

25. Reducing the risk of tick-to-human transmission
WHO recommendations
 wear protective clothing (long sleeves, long
trousers);
 wear light coloured clothing to allow easy
detection of ticks on the clothes;
 use approved acaricides (chemicals intended to
kill ticks) on clothing;

26.  use approved repellent on the skin and clothing;
 regularly examine clothing and skin for ticks; if
found, remove them safely;
 seek to eliminate or control tick infestations on
animals or in stables and barns; and
 avoid areas where ticks are abundant and
seasons when they are most active.

27. Reducing the risk of animal-to-human
transmission
 wear gloves and other protective clothing while
handling animals or their tissues in endemic
areas, notably during slaughtering, butchering
and culling procedures in slaughterhouses or at
home;
 quarantine animals before they enter
slaughterhouses or routinely treat animals with
pesticides two weeks prior to slaughter.

28. Reducing the risk of human-to-human
transmission in the community:
 avoid close physical contact with CCHF-infected
people;
 wear gloves and protective equipment when
taking care of ill people;
 wash hands regularly after caring for or visiting
ill people.

29. CCHF in Pakistan
 From 1 January to 9 June 2013, a total of 16
suspected cases of Crimean-Congo haemorrhagic
fever (CCHF), including six deaths (case–fatality rate
37.5%) were reported from Pakistan.
 So far, 7 of these reported cases have been
laboratory-confirmed.
 In 2012, the country faced a similar outbreak of
CCHF with 61 suspected cases, including 17 deaths
(case–fatality rate 27.8%) reported from the disease.

30.  The majority of the cases were reported from the
province of Balochistan, Sindh, Khyber
Pakhtunkhwa and Punjab.
 Crimean-Congo haemorrhagic fever is endemic in
Pakistan and cases are reported sporadically since
2000.

31. Suspected cases of CCHF reported in Pakistan 2000-2010
Year Case Death Case fatality
2000-2002 191 59 26.2
2003-2006 328 42 12.8
2010 29 3 4.9
2012 61 17 27.8

32. End