Emergencies preparedness, response

Crimean-Congo haemorrhagic fever (CCHF)

NICD South Africa/R. Swanepoel
Ticks of the genus Hyalomma are the principal vector of Crimean-Congo haemorrhagic fever. Female (right), male (left).

Crimean-Congo haemorrhagic fever is a viral haemorrhagic fever transmitted by ticks. It can be responsible for severe outbreaks in humans but it is not pathogenic for ruminants, their amplifying host.

The disease was first described in the Crimea in 1944 and given the name Crimean haemorrhagic fever. In 1969 it was recognized that the pathogen causing Crimean haemorrhagic fever was the same as that responsible for an illness identified in 1956 in the Congo, and linkage of the two place names resulted in the current name for the disease and the virus.

Crimean-Congo haemorrhagic fever (CCHF) spreads to humans either by tick-bites, or through contact with viraemic animal tissues during and immediately post-slaughter. CCHF outbreaks constitute a threat to public health services because of its epidemic potential, its high case fatality ratio (10-40%), its potential for nosocomial outbreaks and the difficulties in treatment and prevention. CCHF is endemic in all of Africa, the Balkans, the Middle East and in Asia south of the 50° parallel north, the geographic limit of the genus Hyalomma, the principal tick vector.

The length of the incubation period depends on the mode of acquisition of the virus. Following infection by a tick bite, the incubation period is usually one to three days, with a maximum of nine days. The incubation period following contact with infected blood or tissues is usually five to six days, with a documented maximum of 13 days.

Onset of symptoms is sudden, with fever, myalgia, (muscle ache), dizziness, neck pain and stiffness, backache, headache, sore eyes and photophobia (sensitivity to light). There may be nausea, vomiting, diarrhoea, abdominal pain and sore throat early on, followed by sharp mood swings and confusion. After two to four days, the agitation may be replaced by sleepiness, depression and lassitude, and the abdominal pain may localize to the upper right quadrant, with detectable hepatomegaly (liver enlargement).

Other clinical signs include tachycardia (fast heart rate), lymphadenopathy (enlarged lymph nodes), and a petechial rash (a rash caused by bleeding into the skin) on internal mucosal surfaces, such as in the mouth and throat, and on the skin. The petechiae may give way to larger rashes called ecchymoses, and other haemorrhagic phenomena. There is usually evidence of hepatitis, and severely ill patients may experience rapid kidney deterioration, sudden liver failure or pulmonary failure after the fifth day of illness.

The mortality rate from CCHF is approximately 30%, with death occurring in the second week of illness. In patients who recover, improvement generally begins on the ninth or tenth day after the onset of illness.

CCHF virus infection can be diagnosed by several different laboratory tests:

  • Enzyme-linked immunosorbent assay (ELISA);
  • Antigen detection;
  • Serum neutralization;
  • Reverse transcriptase polymerase chain reaction (RT-PCR) assay; and
  • Virus isolation by cell culture.

Patients with fatal disease, as well as in patients in the first few days of illness, do not usually develop a measurable antibody response and so diagnosis in these individuals is achieved by virus or RNA detection in blood or tissue samples.

Tests on patient samples present an extreme biohazard risk and should only be conducted under maximum biological containment conditions. However, if samples have been inactivated (e.g. with virucides, gamma rays, formaldehyde, heat, etc.), they can be manipulated in a basic biosafety environment.

General supportive care with treatment of symptoms is the main approach to managing CCHF in people.

The antiviral drug ribavirin has been used to treat CCHF infection with apparent benefit. Both oral and intravenous formulations seem to be effective.

Controlling CCHF in animals and ticks

It is difficult to prevent or control CCHF infection in animals and ticks as the tick-animal-tick cycle usually goes unnoticed and the infection in domestic animals is usually not apparent. Furthermore, the tick vectors are numerous and widespread, so tick control with acaricides (chemicals intended to kill ticks) is only a realistic option for well-managed livestock production facilities.

There are no vaccines available for use in animals.

Reducing the risk of infection in people

Although an inactivated, mouse brain-derived vaccine against CCHF has been developed and used on a small scale in eastern Europe, there is currently no safe and effective vaccine widely available for human use.

In the absence of a vaccine, the only way to reduce infection in people is by raising awareness of the risk factors and educating people about the measures they can take to reduce exposure to the virus.

Controlling infection in health-care settings

Health-care workers caring for patients with suspected or confirmed CCHF, or handling specimens from them, should implement standard infection control precautions. These include basic hand hygiene, use of personal protective equipment, safe injection practices and safe burial practices.

As a precautionary measure, health-care workers caring for patients immediately outside the CCHF outbreak area should also implement standard infection control precautions.

Samples taken from people with suspected CCHF should be handled by trained staff working in suitably equipped laboratories.

Recommendations for infection control while providing care to patients with suspected or confirmed Crimean-Congo haemorrhagic fever should follow those developed by WHO for Ebola and Marburg haemorrhagic fever.


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Department of Pandemic and Epidemic Diseases
World Health Organization
Avenue Appia 20
1211 Geneva 27, Switzerland
Email: edpln@who.int