The Largest Reported Outbreak of CCHF in Hospital Settings: Lessons from Kandahar, Afghanistan.

Crimean–Congo haemorrhagic fever is an emerging infectious disease that is one of the viral haemorrhagic fevers. The case fatality rate can range from 10% to 40%.1WHOCrimean-Congo haemorrhagic fever.https://www.who.int/health-topics/crimean-congo-haemorrhagic-fever#tab=tab_1Date accessed: July 25, 2023Google Scholar Such a disease poses a substantial challenge to public health, particularly in low-income and middle-income countries, where poverty is prevalent and close contact between humans and animals is common.2WHOMeeting on prevention and control of CCHF in the Eastern Mediterranean Region.https://www.who.int/publications/i/item/10665-206164Date: Dec 7–9, 2015Date accessed: July 24, 2023Google Scholar Prevention and control of infection with the Crimean–Congo haemorrhagic fever virus is achieved by avoiding and minimising exposure to infected ticks and avoiding direct contact with infected biomaterial and close contact with infected animals and patients. Many cases occur among people involved in the livestock industry. Hospital-acquired infections can also occur due to improper infection prevention and control, and insufficient clinical knowledge and absence of differential diagnosis to suspect and diagnose Crimean–Congo haemorrhagic fever. Consequently, health-care workers are at high risk of becoming infected. In Afghanistan, Crimean–Congo haemorrhagic fever is one of the priority endemic zoonotic diseases. In 2022, 26 of 34 provinces in Afghanistan reported cases of Crimean–Congo haemorrhagic fever.3WHOInfectious diseases outbreak situation reports.https://www.emro.who.int/afg/information-resources/infectious-disease-outbreak-situation-reports.htmlDate accessed: June 15, 2023Google Scholar With more than 21 million livestock that can host the vector in 34 provinces in a country of 40 million population, the endemicity of Crimean–Congo haemorrhagic fever is understandable.4Food and Agriculture Organization of the United Nations and Ministry of Livestock in AfghanistanNational Livestock Census 2002–2003. OSRO/AFG/212/AFG. Final report.https://www.fao.org/3/i0034e/i0034e00.htmDate: 2006Date accessed: May 22, 2023Google Scholar On April 20, 2023, a person with suspected Crimean–Congo haemorrhagic fever was admitted to a private hospital in Kandahar, Afghanistan. One week later, on April 27, 2023, an additional 48 cases were suspected from the same hospital, with 14 of these cases confirmed by laboratory testing as Crimean–Congo haemorrhagic fever. The confirmed cases included 13 hospital staff members (eight nurses, two medical doctors, a laboratory technician, a hospital administrative staff, and a cleaner) and one hospitalised patient. All cases were recorded within 4 days of the positive diagnosis of the first case, from April 26 to April 29. Laboratory tests used ELISA (VectorCrimean CHF-IgM kit; Vector Best, Novosibirsk, Russia) and RT-PCR (Real Star CCHFV-RT-PCR kit; Altona Diagnostics, Hamburg Germany) kits and 15 cases, including the index case, were confirmed as Crimean–Congo haemorrhagic fever. The turnaround time for laboratory results was approximately 2 days. All suspected cases were observed for 14 days. All individuals with confirmed cases presented various symptoms, including fever, haemorrhage, fatigue, vomiting, abdominal pain, myalgia, epistaxis, ecchymosis, and nausea. People with suspected cases presented with various general manifestations but no haemorrhage. The index case, a housewife aged 40 years with a history of animal contact, was the only reported death due to this outbreak, resulting in a case fatality rate of 2%. Mean age for all suspected cases was 27 (SD 9) years and for confirmed positive cases 28 (SD 9) years (table). 61% of all suspected cases were males. 73% of confirmed cases were males.TableDescriptive statistics of the people involved in the Crimean–Congo haemorrhagic fever outbreak in Kandahar, AfghanistanSuspected cases (n=49)Confirmed cases (n=15)Health-care worker (n=39)Non-health-care worker (n=10)CharacteristicsAge, years<202 (4%)002 (20%)20–3038 (78%)10 (67%)33 (86%)5 (50%)31–406 (12%)3 (20%)5 (13%)1 (10%)≥413 (6%)2 (13%)1 (3%)2 (20%)Mean (SD)27·1 (9·0)28·7 (9·0)25·7 (7·5)32·4 (9·0)SexMale30 (61%)11 (73%)28 (72%)8 (80%)Female19 (39%)4 (27%)11 (28%)2 (20%)OccupationHealth-care worker39 (80%)13 (87%)....Doctor6 (12%)2 (13%)6 (15%)..Nurse24 (49%)8 (53%)24 (62%)..Laboratory technician1 (2%)1 (7%)1 (3%)..Administration3 (6%)1 (7%)3 (8%)..Cleaner5 (10%)1 (7%)5 (13%)..Housewife8 (16%)1 (7%)..8 (80%)No job1 (2%)1 (7%)..1 (10%)Farmer1 (2%)0..1 (10%)Signs and symptoms*Not mutually exclusive.Fever38 (78%)15 (100%)28 (72%)10 (100%)Extreme fatigue21 (43%)13 (87%)18 (46%)3 (30%)Vomiting24 (49%)13 (87%)14 (36%)10 (100%)Malaise18 (37%)12 (80%)17 (44%)1 (10%)Headache29 (59%)14 (93%)19 (49%)10 (100%)Petechia8 (16%)6 (40%)7 (18%)1 (10%)OutcomeRecovery48 (98%)14 (93%)39 (100%)9 (90%)Death1 (2%)1 (7%)01 (10%)Data are n (%), unless otherwise specified.* Not mutually exclusive. Open table in a new tab Data are n (%), unless otherwise specified. WHO Afghanistan, in close collaboration with national and local health authorities, immediately launched a multidisciplinary response to the outbreak that included an investigation team deployed to the hospital; notifying the International Health Regulations focal point and the regional WHO office (Eastern Mediterranean Regional Office); detailed interviews with patients, hospital authorities, and provincial health authorities; providing resources for contact tracing, drugs (ribavirin), and PPE; enhancing laboratory capacity through training and delivery of laboratory supplies; and disseminating public awareness messages to the public and community leaders. This nosocomial outbreak presented a classic epidemiological triangle: infection from a tick-harbouring animal to the first person, this index case resulted in infections in some health-care workers due to little awareness and few infection prevention and control measures, and from health workers to a hospitalised patient and other health facility support staff. Similar nosocomial Crimean–Congo haemorrhagic fever outbreaks were reported in various countries, and especially in the eastern Mediterranean region.2WHOMeeting on prevention and control of CCHF in the Eastern Mediterranean Region.https://www.who.int/publications/i/item/10665-206164Date: Dec 7–9, 2015Date accessed: July 24, 2023Google Scholar Findings and observations from Afghanistan show that transmission due to direct unprotected contact with infected blood, tissue, and secretion is quite common.3WHOInfectious diseases outbreak situation reports.https://www.emro.who.int/afg/information-resources/infectious-disease-outbreak-situation-reports.htmlDate accessed: June 15, 2023Google Scholar In our case, in the hospital setting, we faced human-to-human transmission and all confirmed cases were symptomatic. Our findings revealed that infection prevention and control was compromised during patient examination, laboratory testing, and cleaning after the index case and subsequently. Similar findings were reported by Pshenichnaya and Nenadskaya,5Pshenichnaya NY Nenadskaya SA Probable Crimean-Congo hemorrhagic fever virus transmission occurred after aerosol-generating medical procedures in Russia: nosocomial cluster.Int J Infect Dis. 2015; 33: 120-122Summary Full Text Full Text PDF PubMed Scopus (52) Google Scholar Tsergouli and colleagues,6Tsergouli K Karampatakis T Haidich AB Metallidis S Papa A Nosocomial infections caused by Crimean-Congo haemorrhagic fever virus.J Hosp Infect. 2020; 105: 43-52Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar and Yadav and colleagues7Yadav PD Patil DY Shete AM et al.Nosocomial infection of CCHF among health care workers in Rajasthan, India.BMC Infect Dis. 2016; 16: 624Crossref PubMed Scopus (45) Google Scholar but with a much lower number of cases than in this situation. Having such a large number of infected health-care workers was related to severe discrepancies in implementation of standard infection prevention and control protocol found during our visits: personal-protective equipment (including goggles, gowns, and respirators) were not used or used nominally. Similarly, clothes, contaminated objects, and biological liquids of patients were not handled properly. Furthermore, the patient's isolation was not strictly enforced and visiting was unrestricted. Notably, from one index case, we got 48 suspected cases among which 14 were confirmed, all in one hospital setting. Existing data2WHOMeeting on prevention and control of CCHF in the Eastern Mediterranean Region.https://www.who.int/publications/i/item/10665-206164Date: Dec 7–9, 2015Date accessed: July 24, 2023Google Scholar, 6Tsergouli K Karampatakis T Haidich AB Metallidis S Papa A Nosocomial infections caused by Crimean-Congo haemorrhagic fever virus.J Hosp Infect. 2020; 105: 43-52Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar indicate that percutaneous exposure or contact with infected body fluids were the primary routes of nosocomial transmission in this outbreak of Crimean–Congo haemorrhagic fever. Therefore, during the nosocomial infections, different transmission methods were used simultaneously and played an important role, and should not be neglected. Despite Crimean–Congo haemorrhagic fever being one of the most widespread tick-borne diseases in Afghanistan, the true burden of the disease is still not fully known. Although Crimean–Congo haemorrhagic fever is a notifiable disease, many field-level physicians apparently have difficulties in recognising, differentially diagnosing, and treating this infection. Anecdotal evidence from the field indicated that many cases present without evident haemorrhagic manifestations and patients do not receive the proper medical care. Our findings show that case numbers of Crimean–Congo haemorrhagic fever will increase drastically in health-care settings if infection prevention and control measures are not respected. It is imperative to adhere to the WHO One Health integrated approach, to sustainably balance and optimise the health of people, animals, and ecosystems. Designing and implementing programmes, policies, legislations, and research in which multiple sectors work together to achieve better health outcomes is mandatory; this is crucial to addressing health threats in the animal–human–environment interface.8WHOOne Health.https://www.who.int/europe/initiatives/one-healthDate accessed: May 6, 2023Google Scholar We declare no competing interests.