Crimean-Congo hemorrhagic fever and Eid-Ul-Adha: A potential threat during the COVID-19 pandemic.

Dear Editor,

Pakistan is celebrating Eid‐Ul‐Adha in the first week of August 2020. Eid‐Ul‐Adha is an annual religious festival during which millions of farm animals including goats, cows, sheep, and camels are killed. The celebration of the festival during the COVID‐19 pandemic is quite challenging due to the unprecedented rise in cases in Pakistan. Moreover, the festival is also associated with the epidemics of Crimean‐Congo hemorrhagic fever (CCHF), resulting in substantial morbidity and mortality. ,

CCHF is caused by Nairovirus, which is transmitted by ticks (Hyalomma marginatum) and livestock animals. It is a public health threat in most Muslim countries, where an upsurge of cases is being observed around the time of festive. Currently, Pakistan is experiencing a quadruple burden of COVID‐19, resulting in an overwhelmed health care system. As all the measures of the health authorities in Pakistan primarily revolve around the containment of COVID‐19, there is a high propensity that various other infectious diseases might be neglected. It must be noted that country is not readily prepared to deal with any new epidemic. Approximately 20 000 typhoid cases have been reported in Lahore, one of the COVID‐19 hotspots and the second‐largest city of Pakistan, resulting in an additional burden to the health care system. The outbreak of CCHF is another threat during the pandemic as Eid‐Ul‐Adha is considered the most susceptible time for disease contraction. Pakistan is ranked fourth after Turkey, Iran, and Russia for CCHF cases in the Eastern Mediterranean Region of the World Health Organisation.  The country has reported 49 cases of CCHF (mortality rate: 33%) in 2012 and 60 cases (mortality rate: 8%) in 2013. From 2014 to May 2020, a total of 356 cases have been confirmed and the majority of these cases are reported from June to September every year, a most vulnerable period of CCHF spread. The prevalence of CCHF is widespread in all four major provinces of Pakistan including Baluchistan (38%), Punjab (23%), Sindh (14%), Khyber Pakhtunkhwa (14%). The National Institute of Health (NIH) has issued warnings on high risks of CCHF transmission during the current year.

Advance purchase of animals before Eid‐Ul‐Adha is a common practice in Pakistan. Most of these animals are placed in residential areas, preferably at homes. Moreover, people prefer the self‐slaughter of animals due to the unavailability of butchers during the time of festivity. In‐house slaughtering by professional butchers is also observed as it is considered more convenient than going to abattoirs. These practices facilitate the animal‐to‐human transmission of disease. It is pertinent to mention that CCHF is primarily confined to the rural areas of Pakistan. Thousands of farmers from rural regions migrate to urban areas to sell their animals before the festival. These migratory activities remain uncontrolled and lack health checks on transported animals, resulting in disease spread to the urban regions. In addition, freelancers and nonprofessional slaughterers, low awareness and lack of butchery training, poor regulation on animal sale, animal slaughtering at public places, gathering around the slaughtered animals, inappropriate disposal methods and handling of animal blood, tissues and skin are some factors leading to zoonotic transmission of CCHF to the general community. ,

It is important to note that virus contraction by health care professionals during the management of CCHF patients has been observed in Pakistan. Moreover, deaths of physicians, surgeons, and nurses while treating the CCHF patients have raised substantial concerns in the past. As the COVID‐19 pandemic has already exhausted the under‐resourced health care system in Pakistan, the CCHF endemic would be a serious catastrophe, which may result in multiple mortalities during the on‐going health crisis. As many health care professionals have died during the management of COVID‐19 patients, the outbreak of CCHF might create panic among them which could result in compromised efforts to combat COVID‐19. In this context, the health authorities in Pakistan should take stern measures to control CCHF spread during the era of COVID‐19.

Immediate training programs for health care professionals, checking and reporting animal health, lockdown during Eid‐ul‐Adha, awareness campaigns for the general community, advising local authorities for timely collection and disposal of the waste and carcass of the slaughtered, ensuring the availability of laboratory equipment and essential medicines for the diagnosis and treatment of CCHF at the district level, developing effective standard operating procedures (SOPs) and pest control measures, using pesticides for transported animals, collaborating infectious disease researchers with health care professionals and veterinarians for timely diagnosis and management of CCHF, monitoring the implementation of SOPs in livestock markets, ensuring slaughtering at designated places such as abattoirs, provisioning of necessary resources to hospitals receiving CCHF patients, encouraging the use of hand sanitizers, soaps and disinfectant sprays during and after slaughtering of animals, and initiating effective vector control programmes are some important measures which could be taken at the earliest. We need to keep in check the cross‐border migration of animals during the festival, a collaborative vector control framework among CCHF endemic countries will be of paramount importance to curb the growing encumbrance of the disease during the current COVID‐19 pandemic.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

AUTHOR CONTRIBUTIONS

MHB, AA, and THM conceived the idea. AA and SM retrieved the data. MHB and AA wrote the letter. THM and YHK critically reviewed and provided inputs. All authors approved the final version of the manuscript.