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• W2078161952 abstract "Crimean-Congo hemorrhagic fever (CCHF) is an acute, tick-borne viral disease, affecting only humans and newborn mice, with hemorrhagic manifestations and considerable mortality in humans. CCHF virus circulates in nature in an enzootic tick–vertebrate–tick cycle; migrating birds and livestock transferred from endemic to non-endemic areas may carry large numbers of infected ticks thus spreading the CCHF virus into novel areas. From 2000 through 2008, the infection emerged or re-emerged in Bulgaria, Albania, Kosovo, and Turkey. It has also recently emerged in Greece, where the first human case has been recognized. This has been attributed to mild winters and to the disruption of agricultural activities, both accounting for an increased tick population, as well as to the migration or transportation of tick-infested birds or animals. CCHF cases occurring as an expected event in endemic areas should be notified to clinicians in the international neighborhood. They should be aware of the probability of importation of CCHF cases from endemic areas, of human-to-human transmission, particularly in the nosocomial setting, and of the potential transmission of the virus via tick-infested and infected imported livestock. This novel European CCHF geographic distribution is a challenge for the scientific community of medical microbiologists, epidemiologists, medical entomologists, and veterinarians that could be followed by acceleration of a European Standardized Response at the national, regional, and international level. Crimean-Congo hemorrhagic fever (CCHF) is an acute, tick-borne viral disease, affecting only humans and newborn mice, with hemorrhagic manifestations and considerable mortality in humans. CCHF virus circulates in nature in an enzootic tick–vertebrate–tick cycle; migrating birds and livestock transferred from endemic to non-endemic areas may carry large numbers of infected ticks thus spreading the CCHF virus into novel areas. From 2000 through 2008, the infection emerged or re-emerged in Bulgaria, Albania, Kosovo, and Turkey. It has also recently emerged in Greece, where the first human case has been recognized. This has been attributed to mild winters and to the disruption of agricultural activities, both accounting for an increased tick population, as well as to the migration or transportation of tick-infested birds or animals. CCHF cases occurring as an expected event in endemic areas should be notified to clinicians in the international neighborhood. They should be aware of the probability of importation of CCHF cases from endemic areas, of human-to-human transmission, particularly in the nosocomial setting, and of the potential transmission of the virus via tick-infested and infected imported livestock. This novel European CCHF geographic distribution is a challenge for the scientific community of medical microbiologists, epidemiologists, medical entomologists, and veterinarians that could be followed by acceleration of a European Standardized Response at the national, regional, and international level. Crimean-Congo hemorrhagic fever (CCHF) is an acute, tick-borne viral disease, affecting only humans and newborn mice,1Whitehouse C.A. Crimean-Congo hemorrhagic fever.Antiviral Res. 2004; 64: 145-160Crossref PubMed Scopus (647) Google Scholar with hemorrhagic manifestations and considerable mortality in humans. CCHF virus circulates in nature in an enzootic tick–vertebrate–tick cycle, the ticks of the genus Hyalomma serving as vectors and reservoirs of the virus1Whitehouse C.A. Crimean-Congo hemorrhagic fever.Antiviral Res. 2004; 64: 145-160Crossref PubMed Scopus (647) Google Scholar, 2Charrel R.N. Attoui H. Butenko A.M. Clegg J.C. Deubel V. Frolova T.V. et al.Tick-borne virus diseases of human interest in Europe.Clin Microbiol Infect. 2004; 10: 1040-1055Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar, 3Ergönül O. Crimean-Congo haemorrhagic fever.Lancet Infect Dis. 2006; 6: 203-214Abstract Full Text Full Text PDF PubMed Scopus (799) Google Scholar, 4Fisher-Hoch S.P. Lessons from nosocomial viral haemorrhagic fever outbreaks.Br Med Bull. 2005; 73-74: 123-137Crossref PubMed Scopus (64) Google Scholar and defining the worldwide distribution of the CCHF virus.1Whitehouse C.A. Crimean-Congo hemorrhagic fever.Antiviral Res. 2004; 64: 145-160Crossref PubMed Scopus (647) Google Scholar, 2Charrel R.N. Attoui H. Butenko A.M. Clegg J.C. Deubel V. Frolova T.V. et al.Tick-borne virus diseases of human interest in Europe.Clin Microbiol Infect. 2004; 10: 1040-1055Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar, 5Swanepoel R. Shepherd A.J. Leman P.A. Shepherd S.P. McGillivray G.M. Erasmus M.J. et al.Epidemiologic and clinical features of Crimean-Congo hemorrhagic fever in southern Africa.Am J Trop Med Hyg. 1987; 36: 120-132PubMed Google Scholar, 6Hoogstraal H. The epidemiology of tick-borne Crimean-Congo hemorrhagic fever in Asia, Europe, and Africa.J Med Entomol. 1979; 15: 307-417PubMed Google Scholar Viremia or antibody production has been demonstrated in numerous domestic and wild vertebrates that suffer an asymptomatic infection,1Whitehouse C.A. Crimean-Congo hemorrhagic fever.Antiviral Res. 2004; 64: 145-160Crossref PubMed Scopus (647) Google Scholar, 5Swanepoel R. Shepherd A.J. Leman P.A. Shepherd S.P. McGillivray G.M. Erasmus M.J. et al.Epidemiologic and clinical features of Crimean-Congo hemorrhagic fever in southern Africa.Am J Trop Med Hyg. 1987; 36: 120-132PubMed Google Scholar, 7Nabeth P. Cheikh D.O. Lo B. Faye O. Vall I.O. Niang M. et al.Crimean-Congo hemorrhagic fever.Mauritania. Emerg Infect Dis. 2004; 10: 2143-2149Crossref PubMed Scopus (112) Google Scholar, 8el-Azazy O.M. Scrimgeour E.M. Crimean-Congo haemorrhagic fever virus infection in the western province of Saudi Arabia.Trans R Soc Trop Med Hyg. 1997; 91: 275-278Abstract Full Text PDF PubMed Scopus (101) Google Scholar while reptiles and birds appear to be refractory to infection with the exception of ostriches.1Whitehouse C.A. Crimean-Congo hemorrhagic fever.Antiviral Res. 2004; 64: 145-160Crossref PubMed Scopus (647) Google Scholar Small herbivores are infested by the nymphal stages of ticks, which transmit the virus transstadially.2Charrel R.N. Attoui H. Butenko A.M. Clegg J.C. Deubel V. Frolova T.V. et al.Tick-borne virus diseases of human interest in Europe.Clin Microbiol Infect. 2004; 10: 1040-1055Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar Migrating birds may carry large numbers of infected ticks, thus spreading the CCHF virus into novel areas.1Whitehouse C.A. Crimean-Congo hemorrhagic fever.Antiviral Res. 2004; 64: 145-160Crossref PubMed Scopus (647) Google Scholar Livestock transferred from endemic to non-endemic areas may be infested with infected ticks.8el-Azazy O.M. Scrimgeour E.M. Crimean-Congo haemorrhagic fever virus infection in the western province of Saudi Arabia.Trans R Soc Trop Med Hyg. 1997; 91: 275-278Abstract Full Text PDF PubMed Scopus (101) Google Scholar, 9Bakir M. Ugurlu M. Dokuzoguz B. Bodur H. Tasyaran M.A. Vahaboglu H Turkish CCHF Study Group. Crimean-Congo haemorrhagic fever outbreak in Middle Anatolia: a multicentre study of clinical features and outcome measures.J Med Microbiol. 2005; 54: 385-389Crossref PubMed Scopus (181) Google Scholar, 10Suleiman M.N. Muscat-Baron J.M. Harries J.R. Satti A.G. Platt G.S. Bowen E.T. et al.Congo/Crimean haemorrhagic fever in Dubai. An outbreak at the Rashid Hospital.Lancet. 1980; 2: 939-941Abstract PubMed Scopus (144) Google Scholar, 11Khan A.S. Maupin G.O. Rollin P.E. Noor A.M. Shurie H.H. Shalabi A.G. et al.An outbreak of Crimean-Congo hemorrhagic fever in the United Arab Emirates, 1994-1995.Am J Trop Med Hyg. 1997; 57: 519-525Crossref PubMed Scopus (123) Google Scholar, 12Rodriguez L.L. Maupin G.O. Ksiazek T.G. Rollin P.E. Khan A.S. Schwarz T.F. et al.Molecular investigation of a multisource outbreak of Crimean-Congo hemorrhagic fever in the United Arab Emirates.Am J Trop Med Hyg. 1997; 57: 512-518PubMed Google Scholar Close contact with viremic animals is the second most frequent route of transmission after tick bite.1Whitehouse C.A. Crimean-Congo hemorrhagic fever.Antiviral Res. 2004; 64: 145-160Crossref PubMed Scopus (647) Google Scholar, 2Charrel R.N. Attoui H. Butenko A.M. Clegg J.C. Deubel V. Frolova T.V. et al.Tick-borne virus diseases of human interest in Europe.Clin Microbiol Infect. 2004; 10: 1040-1055Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar Healthcare worker contact with a patient, nosocomial contact of a secondary patient with the index patient,13Gürbüz Y. Sencan I. Oztürk B. Tütüncü E. A case of nosocomial transmission of Crimean-Congo hemorrhagic fever from patient to patient.Int J Infect Dis. 2009; 13: e105-e107Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar family contact, and breastfeeding have been reported as modes of transmission.14Yilmaz G.R. Buzgan T. Irmak H. Safran A. Uzun R. Cevik M.A. et al.The epidemiology of Crimean-Congo hemorrhagic fever in Turkey, 2002-2007.Int J Infect Dis. 2009; 13: 380-386Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar CCHF virus is endemic in parts of Eurasia and Africa, and demonstrates the widest distribution, in an ever-extending range of geographic areas, among all the tick-borne viruses.1Whitehouse C.A. Crimean-Congo hemorrhagic fever.Antiviral Res. 2004; 64: 145-160Crossref PubMed Scopus (647) Google Scholar, 2Charrel R.N. Attoui H. Butenko A.M. Clegg J.C. Deubel V. Frolova T.V. et al.Tick-borne virus diseases of human interest in Europe.Clin Microbiol Infect. 2004; 10: 1040-1055Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar, 3Ergönül O. Crimean-Congo haemorrhagic fever.Lancet Infect Dis. 2006; 6: 203-214Abstract Full Text Full Text PDF PubMed Scopus (799) Google Scholar, 4Fisher-Hoch S.P. Lessons from nosocomial viral haemorrhagic fever outbreaks.Br Med Bull. 2005; 73-74: 123-137Crossref PubMed Scopus (64) Google Scholar, 5Swanepoel R. Shepherd A.J. Leman P.A. Shepherd S.P. McGillivray G.M. Erasmus M.J. et al.Epidemiologic and clinical features of Crimean-Congo hemorrhagic fever in southern Africa.Am J Trop Med Hyg. 1987; 36: 120-132PubMed Google Scholar, 7Nabeth P. Cheikh D.O. Lo B. Faye O. Vall I.O. Niang M. et al.Crimean-Congo hemorrhagic fever.Mauritania. Emerg Infect Dis. 2004; 10: 2143-2149Crossref PubMed Scopus (112) Google Scholar, 9Bakir M. Ugurlu M. Dokuzoguz B. Bodur H. Tasyaran M.A. Vahaboglu H Turkish CCHF Study Group. Crimean-Congo haemorrhagic fever outbreak in Middle Anatolia: a multicentre study of clinical features and outcome measures.J Med Microbiol. 2005; 54: 385-389Crossref PubMed Scopus (181) Google Scholar, 15Ergönül O. Celikbaş A. Dokuzoguz B. Eren S. Baykam N. Esener H. Characteristics of patients with Crimean-Congo hemorrhagic fever in a recent outbreak in Turkey and impact of oral ribavirin therapy.Clin Infect Dis. 2004; 39: 284-287Crossref PubMed Scopus (246) Google Scholar, 16Nabeth P. Thior M. Faye O. Simon F. Human Crimean-Congo hemorrhagic fever.Senegal. Emerg Infect Dis. 2004; 10: 1881-1882Crossref PubMed Scopus (48) Google Scholar, 17Papa A. Christova I. Papadimitriou E. Antoniadis A. Crimean-Congo hemorrhagic fever in Bulgaria.Emerg Infect Dis. 2004; 10: 1465-1467Crossref PubMed Scopus (119) Google Scholar From 2000 through 2008 a considerable number of outbreaks in the community and the nosocomial setting were reported18Vorou R.M. Papavassiliou V.G. Tsiodras S. Emerging zoonoses and vector-borne infections affecting humans in Europe.Epidemiol Infect. 2007; 135: 1231-1247Crossref PubMed Scopus (114) Google Scholar in southeastern Europe; in Bulgaria in 2002, 2003,17Papa A. Christova I. Papadimitriou E. Antoniadis A. Crimean-Congo hemorrhagic fever in Bulgaria.Emerg Infect Dis. 2004; 10: 1465-1467Crossref PubMed Scopus (119) Google Scholar and 2008,19Kunchev A. Kojouharova M. Probable cases of Crimean-Congo haemorrhagic fever in Bulgaria: a preliminary report.Euro Surveill. 2008; 13 (pii: 18845)PubMed Google Scholar and in Albania and Kosovo in 2001, with as yet undefined reservoirs.17Papa A. Christova I. Papadimitriou E. Antoniadis A. Crimean-Congo hemorrhagic fever in Bulgaria.Emerg Infect Dis. 2004; 10: 1465-1467Crossref PubMed Scopus (119) Google Scholar, 20Papa A. Bino S. Llagami A. Brahimaj B. Papadimitriou E. Pavlidou V. et al.Crimean-Congo hemorrhagic fever in Albania, 2001.Eur J Clin Microbiol Infect Dis. 2002; 21: 603-606Crossref PubMed Scopus (149) Google Scholar, 21Papa A. Bozovi B. Pavlidou V. Papadimitriou E. Pelemis M. Antoniadis A. Genetic detection and isolation of Crimean-Congo hemorrhagic fever virus, Kosovo.Yugoslavia. Emerg Infect Dis. 2002; 8: 852-854Crossref PubMed Scopus (117) Google Scholar Social disruption, conflict, and war have been the major factors identified.17Papa A. Christova I. Papadimitriou E. Antoniadis A. Crimean-Congo hemorrhagic fever in Bulgaria.Emerg Infect Dis. 2004; 10: 1465-1467Crossref PubMed Scopus (119) Google Scholar, 20Papa A. Bino S. Llagami A. Brahimaj B. Papadimitriou E. Pavlidou V. et al.Crimean-Congo hemorrhagic fever in Albania, 2001.Eur J Clin Microbiol Infect Dis. 2002; 21: 603-606Crossref PubMed Scopus (149) Google Scholar, 21Papa A. Bozovi B. Pavlidou V. Papadimitriou E. Pelemis M. Antoniadis A. Genetic detection and isolation of Crimean-Congo hemorrhagic fever virus, Kosovo.Yugoslavia. Emerg Infect Dis. 2002; 8: 852-854Crossref PubMed Scopus (117) Google Scholar, 22Vorou R. Pierroutsakos I.N. Maltezou H.C. Crimean-Congo hemorrhagic fever.Curr Opin Infect Dis. 2007; 20: 495-500Crossref PubMed Scopus (134) Google Scholar Similarly to Kenya, Senegal, and South Africa, the 2002 outbreak in Northeastern Anatolia, Turkey, an eastern Black Sea extended geographic region,14Yilmaz G.R. Buzgan T. Irmak H. Safran A. Uzun R. Cevik M.A. et al.The epidemiology of Crimean-Congo hemorrhagic fever in Turkey, 2002-2007.Int J Infect Dis. 2009; 13: 380-386Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar followed several decades of serologic evidence of a zoonotic focus,1Whitehouse C.A. Crimean-Congo hemorrhagic fever.Antiviral Res. 2004; 64: 145-160Crossref PubMed Scopus (647) Google Scholar, 3Ergönül O. Crimean-Congo haemorrhagic fever.Lancet Infect Dis. 2006; 6: 203-214Abstract Full Text Full Text PDF PubMed Scopus (799) Google Scholar, 5Swanepoel R. Shepherd A.J. Leman P.A. Shepherd S.P. McGillivray G.M. Erasmus M.J. et al.Epidemiologic and clinical features of Crimean-Congo hemorrhagic fever in southern Africa.Am J Trop Med Hyg. 1987; 36: 120-132PubMed Google Scholar, 16Nabeth P. Thior M. Faye O. Simon F. Human Crimean-Congo hemorrhagic fever.Senegal. Emerg Infect Dis. 2004; 10: 1881-1882Crossref PubMed Scopus (48) Google Scholar, 23Dunster L. Dunster M. Ofula V. Beti D. Kazooba-Voskamp F. Burt F. et al.First documentation of human Crimean-Congo hemorrhagic fever.Kenya. Emerg Infect Dis. 2002; 8: 1005-1006Crossref PubMed Scopus (52) Google Scholar not preceded by any human case in the country.14Yilmaz G.R. Buzgan T. Irmak H. Safran A. Uzun R. Cevik M.A. et al.The epidemiology of Crimean-Congo hemorrhagic fever in Turkey, 2002-2007.Int J Infect Dis. 2009; 13: 380-386Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar In 2007 and 2008 a considerable number of CCHF confirmed cases occurred in southeastern and western areas of Turkey, which in 2008 contributed 9% of cases.24Yilmaz G.R. Buzgan T. Torunoglu M.A. Safran A. Irmak H. Com S. et al.A preliminary report on Crimean-Congo haemorrhagic fever in Turkey, March–June 2008.Euro Surveill. 2008; 13 (pii: 18953)Google Scholar The infection has spread to previously non-endemic areas of Turkey, near the Aegean coast of the country and in a rural area of Ankara.13Gürbüz Y. Sencan I. Oztürk B. Tütüncü E. A case of nosocomial transmission of Crimean-Congo hemorrhagic fever from patient to patient.Int J Infect Dis. 2009; 13: e105-e107Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar There is serologic evidence, but not clinical evidence as yet, in France, Portugal, and Hungary.1Whitehouse C.A. Crimean-Congo hemorrhagic fever.Antiviral Res. 2004; 64: 145-160Crossref PubMed Scopus (647) Google Scholar, 2Charrel R.N. Attoui H. Butenko A.M. Clegg J.C. Deubel V. Frolova T.V. et al.Tick-borne virus diseases of human interest in Europe.Clin Microbiol Infect. 2004; 10: 1040-1055Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar, 3Ergönül O. Crimean-Congo haemorrhagic fever.Lancet Infect Dis. 2006; 6: 203-214Abstract Full Text Full Text PDF PubMed Scopus (799) Google Scholar In northern Greece the appearance of a fatal human case in June 2008, the first ever reported in Greece, followed serological evidence attributed to the non-pathogenic AP92.25Papa A. Maltezou H.C. Tsiodras S. Dalla V.G. Papadimitriou T. Pierroutsakos I. et al.A case of Crimean-Congo haemorrhagic fever in Greece, June 2008.Euro Surveill. 2008; 13 (pii: 18952)PubMed Google Scholar It is not feasible to speculate whether this was associated with the cases in Bulgaria in March 2008, as retrospective surveys jointly coordinated by public health and veterinary public health sectors are pending. In temperate areas, the pattern of seasonality of CCHF cases reflects the period of year with high tick activity–between spring and early autumn.17Papa A. Christova I. Papadimitriou E. Antoniadis A. Crimean-Congo hemorrhagic fever in Bulgaria.Emerg Infect Dis. 2004; 10: 1465-1467Crossref PubMed Scopus (119) Google Scholar, 20Papa A. Bino S. Llagami A. Brahimaj B. Papadimitriou E. Pavlidou V. et al.Crimean-Congo hemorrhagic fever in Albania, 2001.Eur J Clin Microbiol Infect Dis. 2002; 21: 603-606Crossref PubMed Scopus (149) Google Scholar, 21Papa A. Bozovi B. Pavlidou V. Papadimitriou E. Pelemis M. Antoniadis A. Genetic detection and isolation of Crimean-Congo hemorrhagic fever virus, Kosovo.Yugoslavia. Emerg Infect Dis. 2002; 8: 852-854Crossref PubMed Scopus (117) Google Scholar Climate and environmental changes may trigger community outbreaks.3Ergönül O. Crimean-Congo haemorrhagic fever.Lancet Infect Dis. 2006; 6: 203-214Abstract Full Text Full Text PDF PubMed Scopus (799) Google Scholar, 7Nabeth P. Cheikh D.O. Lo B. Faye O. Vall I.O. Niang M. et al.Crimean-Congo hemorrhagic fever.Mauritania. Emerg Infect Dis. 2004; 10: 2143-2149Crossref PubMed Scopus (112) Google Scholar Mild winters were followed by CCHF outbreaks in Kosovo in 2001 and in Turkey in 2004.3Ergönül O. Crimean-Congo haemorrhagic fever.Lancet Infect Dis. 2006; 6: 203-214Abstract Full Text Full Text PDF PubMed Scopus (799) Google Scholar, 20Papa A. Bino S. Llagami A. Brahimaj B. Papadimitriou E. Pavlidou V. et al.Crimean-Congo hemorrhagic fever in Albania, 2001.Eur J Clin Microbiol Infect Dis. 2002; 21: 603-606Crossref PubMed Scopus (149) Google Scholar Disruption of agricultural activities and expansion of the hare population infested with infected ticks, followed by the reintroduction of cattle and sheep, have been associated with the CCHF outbreaks in the former Soviet Union, Bulgaria, Kosovo, and in the Middle Anatolia Turkish areas.3Ergönül O. Crimean-Congo haemorrhagic fever.Lancet Infect Dis. 2006; 6: 203-214Abstract Full Text Full Text PDF PubMed Scopus (799) Google Scholar Illegal animal transportation accounts for the expansion of the disease.22Vorou R. Pierroutsakos I.N. Maltezou H.C. Crimean-Congo hemorrhagic fever.Curr Opin Infect Dis. 2007; 20: 495-500Crossref PubMed Scopus (134) Google Scholar Animal transportation imposes a risk of international spread from endemic well-prepared countries to non-endemic unprepared ones.22Vorou R. Pierroutsakos I.N. Maltezou H.C. Crimean-Congo hemorrhagic fever.Curr Opin Infect Dis. 2007; 20: 495-500Crossref PubMed Scopus (134) Google Scholar Consequently, even if the CCHF cases occur as a usual or expected event in endemic areas, notification of CCHF cases as a public health emergency of international concern is deemed imperative. Both the International Health Regulations and the Early Warning and Response System are competent tools for the dissemination of this information. Physicians should be aware of the probability of importation of CCHF cases from endemic areas, of human-to-human transmission, particularly in the nosocomial setting, and of the potential transmission of the virus via tick-infested and infected imported animals. Prompt suspicion and diagnosis trigger the timely implementation of infection control measures in the community and the hospital. At this point, the role of the national centers for disease control and prevention is crucial, as they may generate and disseminate warnings and the relevant diagnostic and therapeutic approach to clinicians soon after the emergence or re-emergence of CCHF in the international neighborhood of each distinct country. The administration of ribavirin, oral or intravenous, is recommended by the World Health Organization26World Health Organization. Crimean-Congo haemorrhagic fever. Fact sheet 208. Geneva: World Health Organization; 2001. Available at: http://www.who.int/mediacentre/factsheets/fs208/en/.(accessed May 2009).Google Scholar and it has been associated with higher survival rates, shorter recovery time, and earlier return to normal levels of laboratory parameters.27Ozkurt Z. Kiki I. Erol S. Erdem F. Yilmaz N. Parlak M. et al.Crimean-Congo hemorrhagic fever in Eastern Turkey: clinical features, risk factors and efficacy of ribavirin therapy.J Infect. 2006; 52: 207-215Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar Replacement therapy with blood products, according to the results of the complete blood count, is indispensable in the management of severe CCHF cases. Treatment with ribavirin in suspected cases28Centers for Disease Control and Prevention (CDC). Update: management of patients with suspected viral hemorrhagic fever—United States. MMWR Morb Mortal Wkly Rep 1995; 44:475-9.Google Scholar and post-exposure prophylaxis for healthcare workers potentially exposed to CCHF virus29Smego Jr., R.A. Sarwari A.R. Siddiqui A.R. Crimean-Congo hemorrhagic fever: prevention and control limitations in a resource-poor country.Clin Infect Dis. 2004; 38: 1731-1735Crossref PubMed Scopus (69) Google Scholar should be considered. Experts from all relevant disciplines, experienced medical microbiologists, epidemiologists, medical entomologists, and veterinarians, should reach a consensus regarding yearly monitoring before the active period from March through October. Farmers and animal husbandry workers, who might handle animals imported from the endemic areas of neighboring countries, are potentially high-risk groups even if they reside in a non-endemic country. They should be made aware of the need to consult with the local veterinary authorities, and if indicated the need to conduct serologic examinations on the imported animals, especially those with an evident tick infestation. Veterinary inspections and the accompanying strict recommendations could also prevent any illegal animal transportation among countries so as to reduce the probability of cross-border spread of infected ticks and subsequent expansion of CCHF. The empowerment of the veterinary sector throughout southeastern Europe and the enhancement of their cooperation and rapid information sharing with the human public health sector at the local, national, regional, and international level are highly recommended. In endemic areas, professional groups in contact with animals should be educated to take precautions against contact with ticks and blood or other tissues: the wearing of gloves, use of long trousers and long sleeves if possible, the application of repellents on exposed skin, and the thorough inspection of skin and clothes for ticks. Veterinarians should be trained to convey their knowledge of CCHF epidemiology, mode of transmission, and particularly precautions to farmers of backyard cattle or other animals. They should conduct consultation meetings and guide rural populations on how to minimize the likelihood of acquiring any zoonoses including CCHF, in close collaboration with the public health sector. Free-range areas should be clearly oriented and accurately differentiated from residential and tourist areas. Regular agricultural activities to keep farms neat and tick control measures protect domestic animals from ticks and tick-borne diseases.19Kunchev A. Kojouharova M. Probable cases of Crimean-Congo haemorrhagic fever in Bulgaria: a preliminary report.Euro Surveill. 2008; 13 (pii: 18845)PubMed Google Scholar Serology of imported animals is an important subsidiary to consistent strict measures against illegal animal cross-border trafficking. Medical entomology has a vital role in the characterization of tick species according to international taxonomy, and medical microbiology in the examination of pooled samples of ticks for the CCHF virus RNA. Monitoring of the virus circulation in probable zoonotic foci is of paramount importance in the temperate countries of southern Europe, where there are densely populated coastal areas, many of which are also major tourist destinations. Early virus detection in ticks, large herbivores, and small mammals, particularly when they originate from endemic areas of the same or a neighboring country, is the cornerstone of prevention of human cases. Periodic education of high risk groups by those in the veterinary and public health sectors and regular updating of clinicians also play an important role in the early diagnosis of cases and in the prevention of establishment of the virus in novel areas and the subsequent outbreaks. This will also contribute to the containment and elimination of the disease in already endemic areas." @default.
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• W2078161952 title "Crimean-Congo hemorrhagic fever in southeastern Europe" @default.
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