Crimean Congo hemorrhagic fever in COVID 19 times, an emerging concern in Iraq.

Dear Editor,

Crimean-Congo hemorrhagic fever (CCHF), with a fatality rate of up to 30% in more than 30 countries, is the most severe human viral disease spread by ticks [1,2]. CCHF can be spread to people by tick bites, close contact with sick people, or viremia-positive animals [2]. CCHF is classified in many nations as an emergent arboviral zoonotic disease due to the disease's high fatality rate, rising vector bionomics, and climate change [2].

CCHF was first acknowledged in Tajikistan in the 12th century. The first case of CCHF was documented in the Crimean region of the former Soviet Union in 1944. Subsequent occurrences were later documented in southern Soviet Republics, South Africa, and Bulgaria [3]. According to a recent study, CCHF is widespread throughout 47 nations, including Asia, Africa, the Middle East, and Europe. Since the CCHFV was discovered in 1967, 140 outbreaks have been reported globally [3]. Over 10,000 cases have been reported in Turkey since 2002, making Turkey and Iran the primary epidemic areas [1].

Iraq is one of the nations in the eastern Mediterranean where CCHF is considered endemic [4]. Between 1998 and 2009, there were 0–6 cases of CCHF every year. Twenty-eight suspected cases and 11 confirmed cases were recorded in 2010. Case mortality rates ranged from 4% among suspected cases to 36% among verified cases [5]. There were three recorded fatal cases in 2018; more recently, 33 confirmed cases, including 13 deaths (CFR 39%), were reported in 2021 [4]. Between 1 January and May 22, 2022, Iraq reported 212 cases, of which 115 (54%) were suspected, and 97 (46%) were confirmed; there were 27 fatalities, of which 14 were associated with suspected cases, and 13 were associated with cases that had laboratory confirmation. In comparison to 2021, a lot more cases have been reported [4].

The world, including Iraq, is already recovering from the devastations caused by the COVID-19 pandemic, with impending waves doing the rounds now and then. On top of all these, Iraq has been amidst various wars and insurgencies recently, which include the war in Iraq from 2013-’17, the 2017 Iraqi Kurdish conflict, the Iraqi Insurgency from 2017 (currently ongoing) and the 2017-’19 Syrian Civil war [6]. Although Iraq has been emerging victorious in most instances, war drains away a country's economy massively, which means less economic allocation to the healthcare sectors. On top of all these, COVID-19 has further dwindled all other avenues of healthcare and has been the centre of attraction of the medical fraternity worldwide. CCHF has been endemic in Iraq since 1979, with cases increasing each passing year. But, due to all the mentioned factors, just like many other diseases, even CCHF had moved out of the focus of healthcare policymakers, and the repercussions are evident– 3 cases in 2018 to 33 cases (CFR 39%) in 2021 to 212 cases in just 5 months of 2022 [4].

The measures that the Iraqi government has already taken include deploying an epidemiological investigation team to Thigar governorate, a vector control team, and circulation with the help of various printed educative communication materials highlighting preventive measures. A contact tracing app should be prepared. Additional efforts should be made to break the transmission chain, especially in the rural areas of livestock rearing, including cattle, is common. Subsistent agriculture is common in Iraq, and animal barns are in close proximity to residential areas. Hence, an effort should be made to increase the distance between the two. Also, animal slaughtering increases the risk of transmission. The risk increased during festivities like Eid due to increased slaughtering, and increased population movement led to cross-border transmission. Hence, the Iraqi government needs to be extra alert and pre-prepared with enough health care infrastructure during these times. Wherever possible, well-maintained facilities should be enforced to use acaricides for vector control. Quarantining the lot's healthy animals can also limit the spread if possible early detection. Currently, no vaccines are available for animal immunization, but an inactivated mouse brain-derived vaccine for animal use is under trial. Hence, prevention is the only way out. Such measures include– wearing long-sleeved light coloured shirts and long trousers, using acaricides on clothing and repellants on the skin, regular inspection of clothes for the presence of ticks and, if found, safe and procedural removal, elimination of tick infestations in slaughterhouses, barns and stables, taking extra protection in Tick large areas and tick abundant seasons, use of protective gears during animal handling procedures and also during care of infected or ill people, avoiding close contact with CCHF infected people and regular maintenance of hand hygiene. Infected patients should be in isolation. Other countries, majorly countries around the Iraq, should prepare a standard operating procedures [SOPs] to stop the future spread of the disease. Standard IPC procedures should be followed in settings dealing with patients and samples of suspected and/or lab-confirmed CCHF patients.

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Author statement

Conceptualization: Dattatreya Mukherjee, Vikash Jaiswal.

Writing: Subhajeet Roy, Allison Iturburu, Dattatreya Mukherjee.

Review with Critical Comments: Dattatreya Mukherjee, Vikash Jaiswal.

Editing: Dattatreya Mukherjee.

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