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Crimean-Congo Haemorrhagic Fever (CCHF) Outbreak in Iraq: Currently

emerging situation and mitigation strategies -Correspondence

Article in International Journal of Surgery · September 2022

DOI: 10.1016/j.ijsu.2022.106916

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 International Journal of Surgery 106 (2022) 106916

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International Journal of Surgery

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Correspondence

Crimean-Congo haemorrhagic fever (CCHF) outbreak in Iraq: Currently emerging situation and
mitigation strategies – Correspondence

Dear Editor between 1989 and 2009; 11 cases 2010; three fatal cases were reported
in 2018; and more recently, 33 confirmed cases including 13 deaths
A recent outbreak of Crimean Congo haemorrhagic fever (CCHF), a
(CFR 39%) were reported in 2021 [6]. On 12th August 2022, the World
tick-borne disease with high fatality rate, caused by an arbovirus named
Health Organization (WHO) was notified of confirmed outbreak of CCHF
as Crimean-Congo haemorrhagic fever virus (CCHFV), has posed an
which was ongoing in Saint-Louis region, Senegal (area endemic for
emerging public health concern in Iraq [1]. CCHF is endemic in some
CCHF) [12,13]. The index case is a female patient aged 38 years who
parts of Asia, Africa and Europe [2–5]. The disease has been earlier re­
presented with fever, headache, myalgia, fatigue and haemorrhagic
ported in Iraq (1979–2021). However the current CCHF outbreak is huge
symptoms, and was detected through the VHF (Viral haemorrhagic
and requires immediate attention for its timely prevention and control to
fever) surveillance system. A positive history of travel to Mauritan (area
limit its further expansion [6]. This article describes the current situa­
endemic for CCHF) before initiation of the symptoms and the index case
tion of CCHF outbreak in Iraq along with salient features of this
succumbed to the disease. More recently, a second case, a contact of the
important disease, advances in developing vaccines and therapeutics,
index case was confirmed positive on 14 Aug 2022 [12,13]. According to
and counteracting strategies for its effective prevention and control.
the WHO Report of 14th August 2022 (week 32), 1112 suspected CCHF
CCHFV belongs to the Nairovirus genus in the Bunyaviridae family,
cases were reported, of which 295 were laboratory confirmed, with 86
and causes severe disease in human beings with a reported mortality of
related suspected deaths and 53 deaths among the confirmed cases
3–30% [5,7]. The virus is naturally transmitted by ticks, mostly of the
(representing 17.9% of the case fatality rate). The present number also
Hyalomma genus to non-vertebrate hosts within an enzootic sylvatic life
depicted an increasing trend since an increase of 14% was seen in cases
cycle. These ticks are both the biological vectors as well as reservoirs for
as compared to the previous week [14]. Among the polymerase chain
CCHFV as they are able to maintain the virus for several months or even
reaction (PCR) confirmed cases, a positive history of direct contact with
years [8]. This disease has the most extensive geographical distribution
animals was present and housewives, butchers and livestock breeders
of the medically important tick-borne viral diseases with description in
and traders represented 84% of those reported to be infected with CCHF
more than 30 countries. Humans get infected through tick bites and by
across Iraq. No cases were reported among health care workers. An age
coming in close contact with sick people or viremia-positive animals.
group of 15–44 years and male population were maximally affected
There are reports of nosocomial transmission of CCHF in workers
probably due to occupational exposure [14].
involved in health care due to needle sticks (accidental) or when such
Multidisciplinary outbreak response and risk assessment approach
workers are exposed to the blood, droplets or body fluids of people
have been utilised by health authorities. An epidemiology team was
suffering from CCHF [9]. Following a short incubation period, clinical
formed to conduct an outbreak investigation, which included house-to-
signs of the disease develop usually in less than seven days. Initially
house visits of reported cases, contact tracing and entomological
there is high rise of temperature, myalgia and headache along with
investigation for disease vectors, including collection and classification
gastrointestinal signs. During the second phase of infection there is
of ticks from each site of the reported suspected cases. The vector control
occurrence of haemorrhagic syndrome. In certain instances, there is
team sprayed indoor and outdoor acaricides in affected areas and vet­
bleeding from the skin and mucous membranes [2].
erinary hospitals treated domestic animals with acaricides in affected
The disease was first recognized in Tajikistan in the 12th Century
areas. Information, education, and communication materials which
when a haemorrhagic syndrome was seen [10]. It was not until 1944
outlined prevention and control measures for CCHF were printed and
when the disease came to modern medical attention, when about 200
widely circulated in high risk (butchers and animal barns owners) and
Soviet military personnel were infected while assisting peasants in
general population. Early and aggressive case detection was made
war-devastated Crimean region of the former Soviet Union [11]. Till
possible by WHO collaborating with the MoH (Ministry of Health) of
1970, subsequent epidemics were mostly reported from the former So­
Iraq on availability of diagnostic kits and genomic sequencing [15].
viet Union and Bulgaria. Since then, CCHF is endemic in parts of Asia,
The antiviral drug most extensively used in CCHF is ribavirin.
Africa and the Middle Eastern countries such as Iraq, the United Arab
However, data on the efficacy of this drug in humans have been
Emirates (UAE), Saudi Arabia and Oman, and from Pakistan and China
generated on the basis of observational studies [9]. Assessment of effi­
primarily south of the 50th parallel north – the geographical limit of the
ciency of favipiravir, a broad-spectrum inhibitor of viral polymerase,
principal tick vector of Hyalomma species [4]. By 2000, new outbreaks
conducted in a mouse model revealed the drug to be superior in com­
had been reported from Pakistan, Iran, Senegal, Albania, Yugoslavia,
parison to ribavirin [16]. A combination of plasmapheresis and ribavirin
Bulgaria, Turkey, Kenya and Mauritania [4].
therapy to ameliorate the load of proinflammatory cytokine has been
CCHF has been reported in Iraq as early as 1979 when the disease
found fruitful in severe cases of CCHF [2]. Today, vaccine has been
was initially diagnosed in ten patients. After that six cases were reported

https://doi.org/10.1016/j.ijsu.2022.106916
Received 25 August 2022; Accepted 10 September 2022
Available online 15 September 2022
1743-9191/© 2022 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Correspondence International Journal of Surgery 106 (2022) 106916

globally recognized against CCHFV. However, since 1974, an inacti­ Research registration Unique Identifying number (UIN)
vated vaccine prepared from tissues of brain of newborn mice infected
by the virus has been in use in Bulgaria. Multiple administration of the 1Name of the registry:
vaccine has been done in people above 16 years of age through subcu­ 2 Unique Identifying number or registration ID:
taneous routes [17]. An experimental DNA vaccine based on the viral M 3 Hyperlink to your specific registration (must be publicly accessible
segment has also been developed, which revealed induction of and will be checked)
neutralizing antibodies in mice [9].
As far as minimizing the spread of the disease through the vector., Guarantor
ticks is concerned, active tick surveillance should be carried out. For this
purpose, the distribution, prevalence and rate of CCHFVV infection Ranjit Sah.
among the tick vectors in particular geographical locations need to be
monitored. Application of pesticides should be mandatory at the habitat Data statement
of ticks, and application of insecticides, especially insecticidal dusts
(biodegradable) in tick infested areas is of great value. Residual insec­ All data are included in the manuscript.
ticide treatment of houses, crevices and cavities of furnitures and walls
should be appropriately followed. Measures to control ticks at the pe­ Declaration of competing interest
riphery of forests and villages at high risks should be made mandatory
[18]. No conflicts of interest.
There is requirement of improvement of practices in relation to
prevention and control of CCHF infection in nations where the disease is References
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Kuldeep Dhama**
Ranjit Sah*
Division of Pathology, ICAR-Indian Veterinary Research Institute, Bareilly,
Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu,
Izatnagar, Uttar Pradesh, 243122, India
Nepal
Harvard Medical School, Boston, MA, USA *
Corresponding author. Infectious Diseases Fellowship, Clinical
Aroop Mohanty Research (Harvard Medical School), USA.
All India Institute of Medical Sciences, Gorakhpur, India
E-mail address: [email protected]. **
Corresponding author.
Vibha Mehta E-mail address: [email protected] (R. Sah).
Govind Ballabh Pant Institute of Medical Education and Research, New E-mail address: [email protected] (K. Dhama).
Delhi, India
E-mail address: [email protected].

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