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The main events of epidemiological interest in the last months in the European Union and in the neighbour countries


First evidences of Crimean-Congo Haemorrhagic Fever (CCHF) in Western Europe (Spain)

Crimean-Congo haemorrhagic fever (CCHF) is a widespread disease caused by a tick-borne virus of the genus Nairovirus. The CCHF virus (CCHFV) causes severe haemorrhagic fever outbreaks. The transmission is possible either by bite from infected ticks of the family Ixodidae and genus Hyalomma that are the principal vectors,nevertheless a number of tick genera is capable of becoming infected with virus (Estrada-Pena et al., 2012). CCHFV can also be transmitted by direct contact with blood or tissues from viremic livestock (Ftika et al., 2013; Leblebicioglu et al., 2016). The hosts of CCHFV include a wide range of wild and domestic animals such as cattle, sheep and goats. Animals generally become infected by the bite of infected ticks.


People involved in livestock industry, such as veterinarians, slaughterhouse workers and agricultural workers, constitute the most exposed category to CCHFV. Person-to-person and nosocomial transmission is occasional but not unusual for CCHFV infection when risk is higher for the higher viral loads during the later stages of the disease (Celikbas et al., 2014; Parlak et al., 2015).


In Africa, Balkans, Middle East and Asian countries, where CCHF is endemic, seven genotypes have been recognized by genetic analysis. In the European Union countries,sporadic cases have been reported in Bulgaria and Greece (ECDC 2013; Papa et al., 2008), while in the Balkans CCHFV has a widespread distribution. In the World Health Organization (WHO) European Region, Turkey remains the most affected country.


The incubation period ranges may be different according to the type of transmission and viral load (Vorou et al., 2007; Nabeth et al. 2007). After tick bite transmission the incubation period is almost one to three days, while after exposure to infected blood or bodily fluids may range between three and seven days. This period can be shorter depending to viral load from infected blood (Naderi et al., 2013). Symptoms of CCHF in humans include high fever, muscle pain, dizziness, photophobia, abdominal pain, diarrhoea, vomiting and, in severe cases, systemic haemorrhage (ECDC, 2016).


On 31 August 2016, two cases of infection with CCHFV were reported in Madrid, giving the first evidence of the disease in Spain. The first case was a man of 62 years who likely got infected through a tick-bite while hiking around the community of San Juan del Molinillo (Avilla). Interestingly, the virus was identified in Hyalomma lusitanicum in western Spain, close to the border with Portugal. (Estrada-Pena et al., 2012).


After first symptoms, the man was admitted to the intensive care unit (ICU) of the Infanta Leonor Hospital in Madrid. Afterwards, the man was transferred to a high-level isolation ICU at the Gregorio Marañón Hospital in Madrid where he died on 25 August 2016 (Figure 1). 

Figure 1. The first evidence of CCHF virus in Spain

■ Avilla, Spain, first place where the patient most likely got infected through a tick-bite

● Intensive care unit (ICU) of the Infanta Leonor Hospital, Madrid where the first case was hospitalized and the second case was exposed

▲High-level isolation ICU at the Gregorio Marañón Hospital, Madrid, where the first case was transferred).


Unfortunately, one healthcare worker, who took care of the CCHF affected patient while he was hospitalized in the ICU, developed symptoms a few days later and was hospitalized presenting severe disease, but with favourable evolution. Both cases were confirmed by PCR at the Spanish National Centre for Microbiology.


Both cases represent the first detection of autochthonous infection of CCHF in Spain and Western Europe.


The European Centre for Disease prevention and control (ECDC) published on 8th September 2106 a Rapid risk assessment on CCHF . The document takes into account the risk for tick-borne transmission, the risk for nosocomial transmission and the risk for transmission via substances of human origin, suggesting different options of action.


Recent detection of CCHFV in ticks from the autonomous Community of Extremadura in western Spain, indicates the circulation of CCHF virus among wildlife. Therefore, the occurrence of CCHFV infection is not an unexpected event in Spain. Nosocomial transmission of CCHF can occur even in a non-endemic region when appropriate infection prevention and control (IPC) measures have not been observed. The probability of CCHF virus infection in Spain is low. However, other sporadic cases are possible.




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2. Estrada-Pena A, Palomar AM, Santibanez P, Sanchez N, Habela MA, Portillo A (2012). Crimean Congo hemorrhagic fever virus in ticks, Southwestern Europe, 2010. Emerg Infect Dis. Jan;18(1):179-80.


3. European Centre for Disease Prevention and Control (2014). Annual Epidemiological Report Emerging and vector-borne diseases. . Stockholm: ECDC; 2014.


4. European Centre for Disease Prevention and Control (2016). Factsheet for health professionals: Crimean-Congo haemorrhagic fever (CCHF).


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6. Leblebicioglu H, Sunbul M, Guner R, Bodur H, Bulut C, Duygu F, (2016). Healthcare-associated Crimean-Congo haemorrhagic fever in Turkey, 2002-2014: a multicentre retrospective cross-sectional study. Clin Microbiol Infect;22(4):387 e1-4.


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8. Naderi HR, Sheybani F, Bojdi A, Khosravi N, Mostafavi I (2013). Fatal nosocomial spread of Crimean-Congo hemorrhagic fever with very short incubation period. Am J Trop Med Hyg;88(3):469-71.


9. Papa A, Maltezou HC, Tsiodras S, Dalla VG, Papadimitriou T, Pierroutsakos I, (2008). A case of Crimean-Congo haemorrhagic fever in Greece, June 2008. Euro Surveill;13(33).


10. Parlak E, Koşan Z, Ertürk A, Parlak M, Özkut Z (2015). A nosocomial outbreak of Crimean-Congo hemorrhagic fever. Journal of Microbiology and Infectious Diseases;5(1):5-9.


11. Shayan S, Bokaean M, Shahrivar MR, Chinikar S (2015) Crimean-Congo Hemorrhagic Fever.  Lab Med. 2015 Summer;46(3):180-9.


12. Vorou R, Pierroutsakos IN, Maltezou HC. Crimean-Congo hemorrhagic fever (2007). Curr Opin Infect Dis;20(5):495-500.




Edited by:
Guido Di Donato

Istituto Zooprofilattico Sperimentale dell'Abruzzo e del Molise "G. Caporale"



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