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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 onsetReporting countryNumber of casesPlace of exposureOther informationReferences
2013Bulgaria 8Shumen, Yambol, Haskovo, Kardjali and Blagoevgrad regions, Bulgaria

Transmission: via tick bite.

Outcome: 2 deaths.

[8]
Spain1Ávila province, Castile-León, Spain

Transmission: via tick bite.

Onset of symptoms: May.

Outcome: recovered.

Other: Case detected retrospectively (in 2020).

[7]
2014Bulgaria8Haskovo, Kardjali, Blagoevgrad, Plovdiv and Burgas regions, Bulgaria

Transmission: via tick bite.

Outcome: 1 death.

[9,10]
United Kingdom1Burgas province, Bulgaria

Transmission: via tick bite.

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

Onset of symptoms: June. 

Outcome: recovered.

[9,11]
2015Bulgaria4Blagoevgrad, Haskovo and Yambol regions, Bulgaria

Transmission: via tick bite.

Outcome: 2 deaths.

[12,13]
2016Bulgaria4Blagoevgrad, Kardjali and Yambol regions, Bulgaria

Transmission: via tick bite.

Outcome: recovered.

[14,15]
Spain2Ávila province, Castile-León, Spain

Transmission: via tick bite.

Exposure: during a hike in August.

Onset of symptoms: August.

Outcome: died.

[15-17]
Madrid province, Madrid, Spain

Transmission: nosocomial transmission. 

Exposure: healthcare worker who cared for the index case. 

Onset of symptoms: August. Outcome: recovered.

[15-17]

 

2017Bulgaria2Kardjali and Haskovo regions, Bulgaria

Transmission: via tick bite.

Outcome: recovered.

[18,19]
2018Bulgaria6Kardjali and Plovdiv regions, Bulgaria

Transmission: via tick bite.

Outcome: 1 death.

[20,21]
Greece1Blagoevgrad province, Bulgaria

Transmission: via tick bite.

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

Onset of symptoms: May.

Outcome: recovered.

[21,22]
Spain2Badajoz province, Extremadura, Spain

Transmission: via tick bite.

Exposure: during a hunt in July. 

Onset of symptoms: July. Outcome: died.

[21]
Salamanca province, Castile-León, Spain

Transmission: via tick bite.

Exposure: contact with farm animals.

Onset of symptoms: August.

Outcome: recovered.

[23]
2019Bulgaria2Kardjali region, Bulgaria

Transmission: via tick bite.

Outcome: recovered.

[24,25]
2020Bulgaria1Burgas region, Bulgaria

Transmission: via tick bite.

Outcome: recovered.

[26]
Spain3Salamanca province, Castile-León, Spain

Transmission: via tick bite.

Onset of symptoms: May.

Outcome: recovered.

[27,28]

Transmission: via tick bite.

Exposure: contact with farm animals.

Onset of symptoms: June.

Outcome: recovered.

[27]

Transmission: via tick bite.

Onset of symptoms: August.

Outcome: died.

[27,29]
2021Spain2Salamanca province, Castile-León, Spain

Transmission: via tick bite.

Exposure: contact with farm animals.

Onset of symptoms: April.

Outcome: recovered.

[30]
León province, Castile-León, Spain

Transmission: via tick bite.

Exposure: during a hike.

Onset of symptoms: Early June.

[31]
2022Bulgaria2Zlatoustovo, Haskovo province, Bulgaria

Transmission: unknown, probably via tick bite.

Exposure: via farming.

Onset symptoms: April

Outcome: Recovered 

[32]
Kardzhali, Bulgaria

Transmission: via tick bite

Exposure: unknown

Onset of symptoms: July

Outcome: Died

[32]

2022

 

Spain

 

2

 

León province, Castile-León, Spain

 

Transmission: via tick bite.

Exposure: during a hunt.

Onset of symptoms: July.

Outcome: recovered.

[33,34]

Transmission: via tick bite.

Exposure: working as forestry worker.

Onset of symptoms: June.

Outcome: died.

[34]
2024Spain1Salamanca province, Castile-León, Spain

Transmission: via tick bite.

Exposure: during a hike.

Onset of symptoms: April.

Outcome: died.

[35]

[36]

 

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. Personal communication Head of National Reference Laboratory Vector-borne infections, Bulgaria, November 2023. Message 
  33. 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
  34. 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
  35. Falcón L. Public Health confirms a case of Crimean-Congo hemorrhagic fever in Salamanca [in Spanish: Salud Pública confirma un caso de fiebre hemorrágica de Crimea-Congo en Salamanca], 27 April 2024. El Español; 2024. Available at: https://www.elespanol.com/castilla-y-leon/region/salamanca/20240427/salud-publica-confirma-caso-fiebre-hemorragica-crimea-congo-salamanca/850914940_0.html
  36. COPE. Elderly man with Crimean-Congo haemorrhagic fever dies in Salamanca [in Spanish: Fallece en Salamanca el hombre de avanzada edad con fiebre hemorrágica de Crimea-Congo], 02 May 2024. Available at: https://www.cope.es/actualidad/sociedad/noticias/fallece-salamanca-hombre-avanzada-edad-con-fiebre-hemorragica-crimea-congo-20240502_3277630
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