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Cases of Crimean–Congo haemorrhagic fever in the EU/EEA, 2013–present

Crimean-Congo haemorrhagic fever (CCHF) is a viral disease caused by CCHF orthonairovirus, which is endemic in regions of Africa, the Balkans, the Middle East and western and south-central Asia [1,2]. The virus has caused major outbreaks in EU/EEA neighbouring regions, principally in the Balkan region, Turkey and Russia [3]. CCHF orthonairovirus is typically spread via the bites of ticks of the Hyalomma genus. These ticks are widely distributed across southern and eastern Europe [4]. CCHF orthonairovirus can also be transmitted via direct or indirect contact with blood or the organs of viraemic hosts (animals or humans). Therefore, healthcare workers attending to CCHF patients may be exposed to the virus if they do not take appropriate protective measures.

CCHF was first diagnosed in Bulgaria in the mid-1950s and became endemic in some regions of the country. In Greece, the first and so far only autochthonous case was reported in 2008 [3,5,6]. In 2016, Spain reported its first autochthonous cases in the province of Ávila, Castile-León. A retrospective study, conducted in 2020 and published in 2021, showed that a case of CCHF had occurred in the same province in 2013 [7].

Details of CCHF cases infected in the EU/EEA since 2013 are presented below (Table 1 and Figure 1).

Year of onset

Reporting country

Number of cases

Place of exposure

Gender and age

Other information

References

2013

Bulgaria

8

Shumen, Yambol, Haskovo, Kardjali and Blagoevgrad regions, Bulgaria

One case between 15 and 24 years, six cases between 45 and 64 years and one case above 65 years.

Transmission: via tick bite.

Outcome: 2 deaths.

[8]

Spain

1

Ávila province, Castile-León, Spain

Female aged 32 years.

Transmission: via tick bite.

Onset of symptoms: May.

Outcome: recovered.

Other: Case detected retrospectively (in 2020).

[7]

2014

Bulgaria

8

Haskovo, Kardjali, Blagoevgrad, Plovdiv and Burgas regions, Bulgaria

One case between 5 and14 years, one case between 25 and 44 years, five cases between 45 and 64 years and one case above 65 years.

Transmission: via tick bite.

Outcome: 1 death.

[9,10]

United Kingdom

1

Burgas province, Bulgaria

Male aged 71 years.

Transmission: via tick bite.

Exposure: travel-related, during a stay in Bulgaria.

Onset of symptoms: June.

Outcome: recovered.

[9,11]

2015

Bulgaria

4

Blagoevgrad, Haskovo and Yambol regions, Bulgaria

Two males and two females aged above 65 years.

Transmission: via tick bite.

Outcome: 2 deaths.

[12,13]

2016

Bulgaria

4

Blagoevgrad, Kardjali and Yambol regions, Bulgaria

One female between 15 and 19 years and three males above 60 years.

Transmission: via tick bite.

Outcome: recovered.

[14,15]

Spain

2

Ávila province, Castile-León, Spain

Male aged 62 years.

Transmission: via tick bite.

Exposure: during a hike on 14 August.

Onset of symptoms: 16 August.

Outcome: died.

[15-17]

Madrid province, Madrid, Spain

Female aged 50 years.

Transmission: nosocomial transmission.

Exposure: healthcare worker who cared for the index case between 19 and 23 August.

Onset of symptoms: 27 August.

Outcome: recovered.

[15-17]

 

2017

Bulgaria

2

Kardjali and Haskovo regions, Bulgaria

Two males, between 30 and 34 years and between 45 and 49 years.

Transmission: via tick bite.

Outcome: recovered.

[18,19]

2018

Bulgaria

6

Kardjali and Plovdiv regions, Bulgaria

Two females above 55 years, one male between 20 and 24 years and three males above 50 years.

Transmission: via tick bite.

Outcome: 1 death.

[20,21]

Greece

1

Blagoevgrad province, Bulgaria

Male aged 47 years.

Transmission: via tick bite.

Exposure: travel-related, during a stay in Bulgaria.

Onset of symptoms: 27 May.

Outcome: recovered.

[21,22]

Spain

2

Badajoz province, Extremadura, Spain

Male aged 74 years.

Transmission: via tick bite.

Exposure: during a hunt in July.

Onset of symptoms: 31 July.

Outcome: died.

[21]

Salamanca province, Castile-León, Spain

Male aged 53 years.

Transmission: via tick bite.

Exposure: contact with farm animals.

Onset of symptoms: August.

Outcome: recovered.

[23]

2019

Bulgaria

2

Kardjali region, Bulgaria

One female between 35 and 39 years; one male between 55 and 59 years.

Transmission: via tick bite.

Outcome: recovered.

[24,25]

2020

Bulgaria

1

Burgas region, Bulgaria

Male above 65 years.

Transmission: via tick bite.

Outcome: recovered.

[26]

Spain

3

Salamanca province, Castile-León, Spain

Male aged 69 years.

Transmission: via tick bite.

Onset of symptoms: 31 May.

Outcome: recovered.

[27,28]

53-year old person.

Transmission: via tick bite.

Exposure: contact with farm animals.

Onset of symptoms: 29 June.

Outcome: recovered.

[27]

Male aged 69 years.

Transmission: via tick bite.

Onset of symptoms: 5 August.

Outcome: died.

[27,29]

2021

Spain

2

Salamanca province, Castile-León, Spain

Male aged 59 years.

Transmission: via tick bite.

Exposure: contact with farm animals.

Onset of symptoms: April.

Outcome: recovered.

[30]

León province, Castile-León, Spain

Woman.

Transmission: via tick bite.

Exposure: during a hike.

Onset of symptoms: Early June.

[31]
2022 Spain 2 León province, Castile-León, Spain Male aged 49 years.

Transmission: via tick bite.

Exposure: during a hunt.

Onset of symptoms: 12 July.

Outcome: recovered.		 [32.33]
Male aged 51 years.

Transmission: via tick bite.

Exposure: working as forestry worker.

Onset of symptoms: 19 June.

Outcome: died.		 [33]

 

Figure 1. Regions of infection (in orange) for Crimean-Congo haemorrhagic fever cases infected via tick bites, EU/EEA, 2013–present

CCHF map 14 June 20201

References

  1. World Health Organization (WHO). Factsheet Crimean-Congo haemorrhagic fever. Geneva: WHO. Available at: https://www.who.int/news-room/fact-sheets/detail/crimean-congo-haemorrhagic-fever
  2. Centers for Disease Control and Prevention. Crimean-Congo Hemorrhagic Fever (CCHF) distribution map. Atlanta: CDC. Available at: https://www.cdc.gov/vhf/crimean-congo/outbreaks/distribution-map.html
  3. Maltezou HC, Papa A. Crimean-Congo hemorrhagic fever: risk for emergence of new endemic foci in Europe? Travel Med Infect Dis. 2010 May;8(3):139-43. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20541133
  4. Europena Centre for Disease Prevention and Control (ECDC), European Food Safety Authority (EFSA). Distribution maps of ticks. Stockholm: ECDC. Available at: https://www.ecdc.europa.eu/en/disease-vectors/surveillance-and-disease-data/tick-maps
  5. European Centre for Disease Prevention and Control (ECDC). Crimean-Congo haemorrhagic fever. In: ECDC. Annual epidemiological report for 2018. Stockholm: ECDC, 2019
  6. European Centre for Disease Prevention and Control (ECDC). Surveillance atlas of infectious diseases Stockholm: ECDC. Available at: http://atlas.ecdc.europa.eu/public/index.aspx?Dataset=27&HealthTopic=16
  7. Negredo A, Sanchez-Ledesma M, Llorente F, Perez-Olmeda M, Belhassen-Garcia M, Gonzalez-Calle D, et al. Retrospective Identification of Early Autochthonous Case of Crimean-Congo Hemorrhagic Fever, Spain, 2013. Emerg Infect Dis. 2021 Jun;27(6):1754-6. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34013861
  8. National Center of Infectious and Parasitic Diseases. Crimean-Congo haemorrhagic fever. Sofia: NCIPD; 2013. Available at: https://www.ncipd.org/index.php?option=com_biuletin&view=view&layout=enversion&year=2013&month=50&lang=en
  9. European Centre for Disease Prevention and Control (ECDC). Annual Epidemiological Report – Crimean-Congo haemorrhagic fever. Stockholm: ECDC, 2014
  10. National Center of Infectious and Parasitic Diseases. Crimean-Congo haemorrhagic fever. Sofia: NCIPD; 2014. Available at: https://www.ncipd.org/index.php?option=com_biuletin&view=view&layout=enversion&year=2014&month=52&lang=en
  11. Lumley S, Atkinson B, Dowall S, Pitman J, Staplehurst S, Busuttil J, et al. Non-fatal case of Crimean-Congo haemorrhagic fever imported into the United Kingdom (ex Bulgaria), June 2014. Euro Surveill. 2014 Jul 31;19(30) Available at: https://www.ncbi.nlm.nih.gov/pubmed/25108534
  12. National Center of Infectious and Parasitic Diseases. Crimean-Congo haemorrhagic fever. Sofia: NCIPD; 2015. Available at: https://www.ncipd.org/index.php?option=com_biuletin&view=view&layout=enversion&month=52&year=2015&lang=en
  13. European Centre for Disease Prevention and Control (ECDC). Annual Epidemiological Report – Crimean-Congo haemorrhagic fever. Stockholm: ECDC, 2015
  14. National Center of Infectious and Parasitic Diseases. Crimean-Congo haemorrhagic fever. Sofia: NCIPD; 2016. Available at: https://www.ncipd.org/index.php?option=com_biuletin&view=view&layout=enversion&month=52&year=2016&lang=en
  15. European Centre for Disease Prevention and Control (ECDC). Annual Epidemiological Report – Crimean-Congo haemorrhagic fever. Stockholm: ECDC, 2016
  16. Negredo A, de la Calle-Prieto F, Palencia-Herrejon E, Mora-Rillo M, Astray-Mochales J, Sanchez-Seco MP, et al. Autochthonous Crimean-Congo Hemorrhagic Fever in Spain. N Engl J Med. 2017 Jul 13;377(2):154-61. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28700843
  17. European Centre for Disease Prevention and Control (ECDC). Rapid Risk Assessment - Crimean–Congo haemorrhagic fever in Spain, 8 September 2016. Stockholm: ECDC, 2018
  18. National Center of Infectious and Parasitic Diseases. Crimean-Congo haemorrhagic fever. Sofia: NCIPD; 2017. Available at: https://www.ncipd.org/index.php?option=com_biuletin&view=view&layout=enversion&month=52&year=2017&lang=en
  19. European Centre for Disease Prevention and Control (ECDC). Annual Epidemiological Report – Crimean-Congo haemorrhagic fever. Stockholm: ECDC, 2017
  20. National Center of Infectious and Parasitic Diseases. Crimean-Congo haemorrhagic fever. Sofia: NCIPD; 2018. Available at: https://www.ncipd.org/index.php?option=com_biuletin&view=view&layout=enversion&month=52&year=2018&lang=en
  21. European Centre for Disease Prevention and Control (ECDC). Annual Epidemiological Report – Crimean-Congo haemorrhagic fever. Stockholm: ECDC, 2018
  22. Papa A, Markatou F, Maltezou HC, Papadopoulou E, Terzi E, Ventouri S, et al. Crimean-Congo haemorrhagic fever in a Greek worker returning from Bulgaria, June 2018. Euro Surveill. 2018 Aug;23(35) Available at: https://www.ncbi.nlm.nih.gov/pubmed/30180928
  23. Monsalve Arteaga L, Munoz Bellido JL, Negredo AI, Garcia Criado J, Vieira Lista MC, Sanchez Serrano JA, et al. New circulation of genotype V of Crimean-Congo haemorrhagic fever virus in humans from Spain. PLoS Negl Trop Dis. 2021 Feb;15(2):e0009197. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33617538
  24. National Center of Infectious and Parasitic Diseases. Crimean-Congo haemorrhagic fever. Sofia: NCIPD; 2019. Available at: https://www.ncipd.org/index.php?option=com_biuletin&view=view&layout=enversion&month=52&year=2019&lang=en
  25. European Centre for Disease Prevention and Control (ECDC). Annual Epidemiological Report – Crimean-Congo haemorrhagic fever. Stockholm: ECDC, 2019
  26. National Center of Infectious and Parasitic Diseases. Crimean-Congo haemorrhagic fever. Sofia: NCIPD; 2020. Available at: https://www.ncipd.org/index.php?option=com_biuletin&view=view&layout=enversion&month=52&year=2020&lang=en
  27. Coordination Centre for Health Alerts and Emergencies, Ministry of Health. Rapid risk assessment. Detection of Crimean-Congo hemorrhagic fever in Salamanca [in Spanish]. Madrid: 2020
  28. Junta de Castilla y Léon. Public health confirms a cases of Crimean-Congo haemorrhagic fever in Salamanca [in Spanish: Salud pública confirma un caso de fiebre hemorrágica de Crimea-Congo en Salamanca], 11 June 2020. Valladolid: Consejería de Sanidad; 2020. Available at: https://comunicacion.jcyl.es/web/jcyl/Comunicacion/es/Plantilla100Detalle/1281372051501/NotaPrensa/1284960397145/Comunicacion
  29. Junta de Castilla y Léon. Authorities receive confirmation of a case of Crimean-Congo haemorrhagic fever in Salamanca [in Spanish: La junta recibe la confirmación de un caso de fiebre hemorrágica de Crimea-Congo en Salamanca], 13 August 2020. Valladolid: Consejería de Sanidad; 2020. Available at: https://comunicacion.jcyl.es/web/jcyl/Comunicacion/es/Plantilla100Detalle/1284877983892/NotaPrensa/1284976629219/Comunicacion
  30. Junta de Castilla y Léon. Public health confirms a cases of Crimean-Congo haemorrhagic fever in Salamanca [in Spanish: Salud pública confirma un caso de fiebre hemorrágica de Crimea-Congo en Salamanca], 26 April 2021. Valladolid: Consejería de Sanidad; 2021. Available at: https://comunicacion.jcyl.es/web/jcyl/Comunicacion/es/Plantilla100Detalle/1284877983892/NotaPrensa/1285048981232/Comunicacion
  31. Junta de Castilla y Léon. Public health confirms a cases of Crimean-Congo haemorrhagic fever in El Bierzo [in Spanish: Salud pública confirma un caso de fiebre hemorrágica de Crimea-Congo en El Bierzo], 10 June 2021. Valladolid: Consejería de Sanidad; 2021. Available at: https://comunicacion.jcyl.es/web/jcyl/Comunicacion/es/Plantilla100Detalle/1284877983892/NotaPrensa/1285065354547/Comunicacion
  32. Junta de Castilla y Léon. Public health confirms a cases of Crimean-Congo haemorrhagic fever in el Bierzo [in Spanish: Salud pública confirma un caso de fiebre hemorrágica de Crimea-Congo en el Bierzo], 20 July 2022. Valladolid: Consejería de Sanidad; 2022. Available at: https://comunicacion.jcyl.es/web/jcyl/Comunicacion/es/Plantilla100Detalle/1281372051501/Comunicado/1285190509128/Comunicacion
  33. Ministerio de Sanidad. Detection of Crimean-Congo haemorrhagic fever cases in el Bierzo [in Spanish: Detección de casos de Fiebre hemorrágica de Crimea-Congo en el Bierzo], 5 August 2022. Madrid: Ministerio de Sanidad; 2022. Available at: https://www.sanidad.gob.es/profesionales/saludPublica/ccayes/alertasActual/Crimea_Congo/docs/20220805_Crimea_Congo_El_Bierzo.pdf