Unraveling the ecological complexities of tick-associated Crimean-Congo hemorrhagic fever virus transmission: a gap analysis for the western Palearctic.

This review aims to summarize the current knowledge of the eco-epidemiology of Crimean-Congo hemorrhagic fever (CCHF) virus transmission reviewing the most recent scientific advances in the last few decades of epidemic and non-epidemic ("silent") periods. We explicitly aim to highlight the dynamics of transmission that are still largely unknown. Recent knowledge gathered from research in Africa and Europe explains the very focal nature of the virus, and indicates that research on the ecology of the virus in the inter-epidemic periods of the disease has not yet been addressed. Hyalomma spp. ticks have been incriminated in the transmission of the virus under field conditions, but the role of other ticks found infected in nature remains to be tested under experimental conditions. Published evidence suggests that the increase in human cases reported in the Balkans, Turkey, and Russia is perhaps less due to the effect of changes in climate, but rather result from the impact of yet unexplored mechanisms of amplification that might be supported by wild animal hosts. Assessment of the available data suggests that epidemics in Eastern Europe are not the result of a spreading viral wave, but more likely are due to a combination of factors, such as habitat abandonment, landscape fragmentation, and proliferation of wildlife hosts that have exacerbated prevalence rates in tick vectors. There is an urgent need to empirically demonstrate these assumptions as well as the role of birds in introducing infected ticks, and also to evaluate the potential for survival of introduced ticks. Either a replacement of the pathogenic virus in the western Mediterranean or a lack of westward dissemination of infected tick populations may explain the absence of the virus in Western Europe.