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Eurosurveillance, Volume 11, Issue 29, 20 July 2006
Articles

Citation style for this article: Editorial team. Increase in cases of Crimean-Congo haemorrhagic fever, Turkey, 2006. Euro Surveill. 2006;11(29):pii=3003. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3003

Increase in cases of Crimean-Congo haemorrhagic fever, Turkey, 2006

Editorial team (eurosurveillance.weekly@hpa.org.uk), Eurosurveillance editorial office

Between 1 January and 30 June 2006, 323 people in Turkey underwent investigation for Crimean-Congo haemorrhagic fever (CCHF) virus infection [1]. Among these, 150 cases were laboratory confirmed using enzyme-linked immunosorbent assay (ELISA) and real-time PCR tests. These laboratory-confirmed cases, including 11 fatal cases, were reported from 22 Turkish provinces. The six provinces in Kelkit Valley, northeastern Turkey are the most affected (Tokat, Sivas, Gümüshane, Amasya, Yozgat and Corum provinces, figure 1). Most of the people investigated reported having been bitten by ticks.

No cases have been reported from popular tourist resorts on the Mediterranean coast. In the past three years, the annual number of cases (and deaths) was 150 (6) in 2003; 249 (13) in 2004, and 266 (13) in 2005. Compared with previous years, the 150 confirmed cases in 2006 so far suggest increased activity of the virus in the area, although detection, diagnosis and notification may have improved.

Figure 1. Provinces most affected, Crimean-Congo haemorrhagic fever, Turkey, as of 30 June 2006.

Control measures implemented in Turkey
Turkey’s Ministry of Health has implemented control measures, in collaboration with the Ministries of the Environment and of Agriculture and Rural Affairs, and enhanced CCHF surveillance has been established nationwide. Case management guidelines, including a treatment protocol with ribavirin, have been distributed to health care facilities throughout Turkey. Four reference hospitals with isolation facilities have also been identified in Ankara, Erzurum, Sivas and Samsun. People in the occupational categories most at risk have been alerted and informed about personal protective measures. Public awareness campaigns are ongoing, stressing personal protective measures to avoid tick bites, and targeting the rural population through television, radio, posters and leaflets, and the Turkish Ministry of Health has made information available on its website [3].The World Health Organization Country Office in Turkey and the WHO Regional Office for Europe are sharing information with the Turkish Ministry of Health to closely monitor the evolution of the disease activity

Crimean-Congo haemorrhagic fever
CCHF viral infections are endemic in many countries in Africa, eastern Europe and Asia, and occur also in the Middle East. Previous outbreaks in Europe have been reported in Turkey in 2001-2003 (83 cases), in Kosovo and in Albania in 2001 (18 and 8 cases respectively). CCHF is a severe disease in humans, with a high mortality rate of around 30%, with death occurring in the second week of illness [4]. Following infection via tick bite, the incubation period is usually one to three days, with a maximum of nine days. Haemorrhage is typical of established viral haemorrhagic fevers, and represents a hazard to healthcare workers if universal precautions are not strictly followed. Early treatment with oral or intravenous ribavirin may shorten and ameliorate the illness, so suspicion of the diagnosis can benefit both patient and carers.

The CCHF virus belongs to (and is the most important human pathogen of) the Nairovirus group of viruses which are transmitted mainly by ticks of the Hyalomma genus. The animal reservoirs for the CCHF virus include hares, birds, ticks, cattle, sheep and goats. Humans who become infected with CCHF acquire the virus from direct contact with blood or other infected tissues from livestock (or possibly another human), or they may become infected from a tick bite. The majority of cases have occurred in those involved with the livestock industry, such as agricultural workers, slaughterhouse workers and veterinarians.

Advice to travellers to northeastern Turkey
The European Centre for Disease Prevention and Control advises travellers to the affected area to take general preventive measures to minimise the exposure to tick bites [2]:

Minimise exposure, wearing light-coloured clothing (this makes it easier to see ticks) covering arms and legs; tuck trousers into socks and keep sleeves rolled down.
Use insect repellent on the exposed skin (eg, DEET 30%) and on clothes (eg, permethrin); before using repellents, pregnant women and children under the age of 12 years should consult a physician or pharmacist.
Inspect the body after possible exposure, and remove ticks immediately by steady, gentle traction, using forceps or tweezers. When removing the tick, protect hands with gloves or tissue. Grasp the tick as close to the skin as possible, and rotate the tick 1-2 times, pulling back gently but firmly. Avoid leaving mouth parts in the skin. Wash the affected area with water and soap, and disinfect with iodine. Observe the area for a few days, and consult a doctor if a pustule, rash or other signs develop at the site of the bite.

People who have travelled to any endemic area and develop symptoms after a tick bite should contact their physician.

Acknowledgements
Thanks to Dr Evelyn Depoortere, European Centre for Disease Prevention and Control

References:
  1. World Health Organization Regional Office for Europe. 6 July 2006 - Crimean-Congo Hemorrhagic Fever (CCHF) activity in Turkey. (http://www.euro.who.int/surveillance/outbreaks/20060706_2)
  2. ECDC. Crimean-Congo hemorrhagic fever – information for travellers to north-eastern Turkey. 20 July 2006. (http://www.ecdc.europa.eu)
  3. T.C. SAGLIK BAKANLIGI Temel Saglik Hizmetleri Genel Müdürlügü. Kirim-Kongo Kanamali Atesi. [In Turkish] (http://www.kirim-kongo.saglik.gov.tr/)
    4. WHO. Crimean-Congo haemorrhagic fever fact sheet 208. November 2001. (http://www.who.int/mediacentre/factsheets/fs208/en/)

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