Iraqi guidelines for CCHF management

January 2023
Table of Contents

Acknowledgement: ............................................................................................. 3
Guideline’s Committee: ....................................................................................... 3
Contributors: ....................................................................................................... 3
Abbreviations: ..................................................................................................... 4
Introduction: ........................................................................................................ 5
Background: ....................................................................................................... 6
Methodology: ...................................................................................................... 7
Disease Transmission:........................................................................................ 7
Risk group: ......................................................................................................... 7
Incubation period: ............................................................................................... 8
Clinical features: ................................................................................................. 8
1- Viraemia phase:....................................................................................... 9
2- Hemorrhagic phase: ................................................................................ 9
3- Convalescent phase: ............................................................................... 9
Differential diagnosis:.......................................................................................... 9
Investigations: ................................................................................................... 10
Complete blood count: .................................................................................. 10
WBC:............................................................................................................. 10
Haemoglobin: ................................................................................................ 11
Platelet count (Plt): ........................................................................................ 11
Bleeding profile: ............................................................................................ 11
Liver enzymes: .............................................................................................. 11
PCR: ............................................................................................................. 11
CCHF IgM/IgG ELISA: .................................................................................. 11
CCHF Case Definition:...................................................................................... 11
Suspected Case: ........................................................................................... 12
Probable Case: ............................................................................................. 12

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 Confirmed: .................................................................................................... 12
Confirmed Cases by severity: ........................................................................... 13
Mild: .............................................................................................................. 13
Moderate: ...................................................................................................... 13
Severe Life-threatening: ................................................................................ 13
Management: ...................................................... Error! Bookmark not defined.
General: .......................................................... Error! Bookmark not defined.
Specific: ........................................................................................................ 16
In the Viraemia phase: .................................................................................. 16
In the hemorrhagic phase: ............................................................................. 16
Platelet transfusion: ....................................................................................... 16
Fresh Frozen Plasma: ................................................................................... 17
Cryoprecipitate: ............................................................................................. 17
Ribavirin: ....................................................................................................... 17
IV IMMUNOGLOBULIN (IVIG): ..................................................................... 17
Convalescent plasma therapy: ...................................................................... 17
Favipravir tablets & H.Chloroguine: ............................................................... 17
CCHF hyperimmunoglobulin: ........................................................................ 17
Vaccine: ........................................................................................................ 18
Infectivity period: ........................................................................................... 19
Prophylaxis Protocol: ........................................................................................ 20
CCHF Follow-up case sheet:......................................................................... 21
21
Discharging Criteria: ...................................................................................... 22
References ..................................................... Error! Bookmark not defined.

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Acknowledgement:
Appreciate and express our deepest thanks for whole efforts and work done by the ministry of
health, especially the Community department especially to the Iraqi CDC group and WHO in
Iraq to build up Iraqi guideline for CCHF management and to all our Iraqi consultants,
specialists, nurse staff, all workers, and administrators in the field of CCHF management.

Guideline’s Committee:
Professor Dr Haitham Noaman Al-koubaisy, MBCHB Baghdad DM. CABM. FRCP
University of Anbar college of medicine
Dr. Khdair Hazbar Razzaq.MD.head of medical department at Al Hussain
teaching hospital Thiqar- Province
Dr. Azhar kareem Razzaq Al-asady, MBChB, F.I.B.M.S(clinical hematology)
Thiqar- Province

Contributors:
Dr. Dheaa Ghanim Alnayli, MBChB ALKUFA, D.M., F.I.C.M.S, Al-Diwaniyah
Province
Dr. Goran Muhedeen Hama Raza, Specialist (Internal Medicine), Sulaymaniyah
Province
Dr. Abbas Faraj Khalaf Al-Baloy, MBChB, F.I.B.M.S, Wasit Province
Dr. Mohannad Abdul Ameer Abdulrahman, CABMS, Karbalaa Province
Dr. Iamael Abdulrahman Hamadamin, MBChB, F.I.B.M.S, Erbil Province
Dr. Anwar Ghani Almosawi, MBChB. FIBMS, Babylon Province
Dr. Oday Zaki Abdul Majeed, MBChB, D.M
Dr. Ahmed Sabbar Hussein, MBChB, F.I.C.M.S, F.I.C.C.S Baghdad Province
Dr. Rafid Thair Habeeb, M. B. CH. B, F. I. C. M. S, Dyala Province
Dr Ahmed Abdul Ameer Ghalib, MBChB, CABMS, Kirkuk Province
Dr. Muntasir Khudir Saod Alkhafajy, FIBMS. CM, Karbala Province
Dr. Didar Rizgar Aziz
Dr. Hassanain Rashid Khaleel, MBChB, MRCPS, MSc. Chest Diseases, Salah
Adin Province
Dr. Ali Kareem Bohan, MBChB, C.A.B.M.S, Basra Province
Dr. Beena H. Shawki, MBChB, FKBMS/CM, MOH/ KRG
Dr. Ali Abdulrahman Al-Tabbakh, MBChB, FKBMS, Erbil Province
Dr. MOHAMMAD ABDUL GHAFOOR MOHAMMAD, MBChB, M.D , C.A.B.MS,
Basra Province.

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 Dr. Samia Ihsan Hassan, MBChB, Higher Diploma of Family Medicine, Public
health directorate
Dr. Hanadi Muhammad Abdul-Sahib, MBChB, F.I.C.M.S. FM, Baghdad Province
Dr. Sarah Saad Hussein, MBChB, F.I.C.M.S.FM, MOH, Directorate of technical
affairs
Dr. Ali Raheem Muhammad, MBChB, F.I.B.M.S. Hematology, Al-Muthanna
province
Dr. Taghlub Hemmed Ryhan, MBChB, HDFM, Kirkuk Province
Dr. Hasan Yassin Hasan, MBChB -F.I.C.M, Dyala Province
Dr. Aws Tariq Jasim, Pulmonologist, MBChB. MSC. Baghdad Province
Dr. Karrar Alaa Shakir, MBChB F.I.B.M.S, Baghdad Province
Dr. Sinan Ghazi Mahdi, MBChB, FICMS, Manager of CDC- Baghdad/ Iraq

Abbreviations:

MOH Ministry of Health

PHD Public Health Directorate
CDC Communicable Diseases Control Center in Baghdad
CCHF Crimean Congo Hemorrhagic fever
CDC Centers for disease control and prevention
WHO World health organization
WBC White blood cell
plt platelet
PT Prothrombin time
aPTT Activated prothrombin thromboplastin time
INR International normalized ratio
DIC Disseminated intravascular coagulation
DLOC Disturbed level of consciousness
ICH Intracranial hemorrhage
PCR Polymerase chain reaction
ELISA enzyme-linked immunosorbent assay
TTP Thrombotic thrombocytopenic purpura
AST Aspartate transaminase
ALT Alanine transaminase
TSB Total serum bilirubin

4
Introduction:
Crimean-Congo Hemorrhagic Fever (CCHF) is caused by infection with a tick-
borne virus (Nairovirus) in the family Bunyaviridae. The disease was first
characterized in Crimea in 1944 and given Crimean hemorrhagic fever name. It
was then later recognized in 1969 as the cause of illness in the Congo, thus
resulting in the current name of the disease.

Crimean-Congo hemorrhagic fever is found in Eastern Europe, particularly in the

former Soviet Union, throughout the Mediterranean, in northwestern China,
central Asia, southern Europe, Africa, the Middle East, and the Indian
subcontinent, most of countries around Iraq like Iran, Turkey, Syria and Saudi
Arabia (1). Most of Iraqi governorates main towns locate around a river
surrounded by villages, most of villages farmers harboring cattle where may be
parasitized with ticks infected with CCHF. So why the hardest infection occurs in
south of Iraq and the majority of cases of CCHF where in Thiqar Province which
recorded about half of the cases on 2022(2). Less cases occur in north, west and
east of Iraq including Baghdad the capital city (2,3,5).
Ixodid (hard) ticks, especially those of the genus, Hyalomma, are both a reservoir
and a vector for the CCHF virus. Numerous wild and domestic animals, such as
cattle, goats, sheep, and hares, serve as amplifying hosts for the virus. These
animals begin to increase in their numbers in spring weather and summer where
the peak of cases occur, in other weathers the cases occur but less in frequency
(1,4).

Transmission of the CCHF to humans occurs through exposure to infected ticks

which parasitize the cattle or contact with infected animal blood or fresh meat
through human wounds. Transmission from infected human to others by contact
with infectious blood or body fluids (1,3). CCHF occur in hospitals due to improper
sterilization of medical equipment and contamination of medical supplies.

Risky people: Are those in contact with infected cattle like livestock career,
Butchers, slaughterer, veterinary doctors and staff, housewives in contact with
infected cattle meat in non-healthy low educated manner. Healthcare workers in
endemic areas risk infection through unprotected contact with infectious blood
and body fluids patients. Individuals and international travelers with contact with
livestock in endemic regions may also be exposed.

Most of our CCHF cases presented with sudden onset with generalized
headache, high grade fever, backache, arthralgia, stomach pain, vomiting then in
day 4-7 begin to develop cutaneous large areas of severe bruising, severe
nosebleeds and uncontrolled bleeding at injection sites can be seen. On
examination the patients were ill, Red eyes, a flushed face, a red throat, and
5
petechiae (red spots) on the palate are common, ecchymosis in large spot in
extremities, trunk and face may occur. Some patients developed jaundice with
hepatosplenomegaly (1-4). Complications occur like shock with multi-organ
failure where the prognosis is poor, hepatic failure with hepatic encephalopathy,
intra-pulmonary hemorrhage with respiratory failure which necessitate invasive
endotracheal intubation with ventilatory support where it is carrying poor
prognosis, neuropsychiatric presentation (changes in mood and sensory
perception ) which indicate CCHF encephalitis we were unable to prove by
cerebrospinal fluid PCR for CCHF study due to high risk of CNS bleeding, it
carries poor prognosis also(6). Fatality rates in hospitalized patients have ranged
from 9- 50%. Where the range of CCHF mortality in Iraq about 25%(2,6).

Background:
Iraq was exposed to hard strike by Hemorrhagic fever over two years, 2021-2022,
in a type of CCHF as the commonest virus; other types may be found with no solid
evidence to declare this.

There was a diversity of cases in a clinical presentation which necessitated

cooperation and coordination among Physicians who dealt with the cases in
context of care and management.

MOH/PHD/CDC/ Baghdad, with the cooperation of WHO conducted a two-day

meeting on 27th -28th December 2022. The attendees were Physicians from all
Provinces with a higher degree of qualification who take care of CCHF cases to
discuss the different clinical aspects of the disease and the management of cases.
Each team presented its cases and are discussed by others.

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The objective of this two days meeting is to draft Iraqi guideline for the CCHF
Management according to the previous international experience and Iraqi
physician's experience

Trend of CCHF in Iraq 1986 - 2022

380
400
350
300
250
200
150
100
48
45
41

35
33
32
25

25
25
24
19

19
18

17

16
11

11
50

9
8

7
6
4

3
3

3
2

2
0
0

0
0

0
0
1995

2007
1986
1987
1988
1989
1990
1991
1992
1993
1994

1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006

2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Methodology:
Professors, Consultants and specialists of Internal medicine, infectious diseases,
clinical hematologists, microbiologists, laboratory virologists, and epidemiologists
from all Health Directorates, Iraqi CDC specialists, Ministry of Health specialists
and WHO specialists participated in this conference throughout 27-28 December
2022 in Baghdad.

For drafting the guideline and opening the window for research, the participants
agreed on the importance of the Guideline, which should be updated every 6-12
months.

Transmission of the disease in Iraq:

Data reported from the Iraq CDC reveals that 37% of confirmed cases exposed
to tick bites, 55% exposed to contact with infected fresh meat, especially
housewives and butchers (1,3).

Risk group:
CDC Data suggest that 57% of confirmed cases have an history of contact with
animals, and 26% have an history of slaughtering.
Regarding gender,40% of cases were female, and 33% were housewives, which
might be explained by their exposure to infected fresh meat during the cooking or
because Iraq culture behavior that women care with animals.
16% and 10% of the confirmed CCHF cases were among butchers and animal
owners, respectively.

7
Our observation shows that a sharp increase of CCHF after Eid Al-Athha, which
might be explained by extensive slaughtering of infected cattle during this
religious festival. The most affected age group is 25-44 years of age (38%) and
(45%) for cases and Mortalities, respectively (1-3,5-6).

Special People: Two pregnant ladies were infected fully managed, but they were
unfortunately died so pregnancy with hemorrhagic fever have poor prognosis.
Children of less than 17 years of age were 16 patients infected with CCHF
unfortunately 2 of them died (1,6).

Key preparedness activities in the healthcare setting

Is all activity manner to prevent CCHF especially at expected started time of
outbreak in spring and summer

Incubation period:
The incubation period 1-7 days
Those exposed to tick bite usually 1-3 days. Some cases of non-tick-bite
transmission of CCHF 7 days and rarely 14 days(1,4).

Clinical presentation:
Full clinical approach is mandatory for those dealing with CCHF as the clinical
symptoms and signs are not specific and there are many differential diagnoses
so full history taking, precise physical examination and ancillary investigations are
very important in reaching the provisional diagnosis as explained below.

Figure 1 Presentation of CCHF (1)

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1- Non-Hemorrhagic phase (Viraemic phase):
This includes high grade fever, headache, arthralgia, and myalgia, nausea,
vomiting, diarrhea continued for seven days coincides with high viral load in
serum(1).

2- 2- Hemorrhagic phase:
Where the patients will have epistaxis, gum bleeding, and ecchymosis and may
develop upper limbs compartment syndrome due to bleeding in the muscles,
upper gastrointestinal bleeding may create gush of hematemesis, intrapulmonary
hemorrhage, or intracranial hemorrhage. This phase is the most serious. If
patients pass this phase which starts from 7-12 days of illness and lasts on
average 2-3 days, they may pass into the convalescent phase (1).

Revision of Iraqi surveillance data reveals that 27%, 26%, 18%, 10% and 5%
presented with bleeding tendency from injection sites, ecchymosis, gums,
epistaxis, and GIT, respectively.

3- Convalescent phase:
It is the phase of recovery where symptoms and Signs start subsiding.

Physical examination:
the patients were ill, red eyes, a flushed face, a red throat, and petechiae (red
spots) on the palate are common, ecchymosis in large spots in extremities, trunk
and face may occur. Some patients developed jaundice with
hepatosplenomegaly.

Complications occur like shock with multi-organ failure where the prognosis is
poor, hepatic failure with hepatic encephalopathy, intra-pulmonary hemorrhage
with respiratory failure which necessitate invasive endotracheal intubation with
ventilatory support where it carries poor prognosis, neuropsychiatric presentation
(changes in mood and sensory perception, seizure, coma) which indicate CCHF
encephalitis we were unable to prove by cerebrospinal fluid PCR for CCHF study
due to high risk of CNS bleeding, it carries poor prognosis also.

Differential diagnosis:
Hematological dyscrasia, Immune thrombocytopenic purpura, connective
tissue disease, meningoencephalitis, and other viral, bacterial, or zoonotic
infections.

9
Investigations:
All our patients were in isolation hospitals blood collected under complete
aseptic technique by professional laboratory staff sent for all laboratory test
locally and sent for CCHF PCR in Central Health Laboratory in Baghdad by
sealed container transmitted by Health directorate vehicle with authorized
health Directorate personnel.

Figure 2 presentation of patients with its hematological and immunological parameters (7)

Complete blood count:

This is a crucial alert for diagnosis and follow-up with a prognostic marker.

WBC:
There will usually be leucopenia, while leukocytosis is usually associated with
a poor prognosis.

10
Hemoglobin:
Follow for anemia due to bleeding or hemolysis might be due to ribavirin drug
therapy.

Platelet count (Plt):

Decrease usually occurs early in the hemorrhagic phase, the degree of
thrombocytopenia associated with poor prognosis, and its elevation with
treatment indicates improvement or cure.

This CBC should be done repeatedly during the inpatient management course of
the patients because it may be changed daily, which affects the management
scenario.

Bleeding profile:
Includes PT and INR, aPTT, serum fibrinogen and D-dimer where elevated PT, INR,
aPTT, and decreased S. fibrinogen with elevated D-dimer indicate DIC.

Liver enzymes:
Where they are elevated in the viremic and hemorrhagic phases and decrease in
the convalescent stage, elevated liver enzymes are not always associated with
poor prognosis.

PCR for CCHF:

Best to be done in the Viremic phase (4).
PCR study for other hemorrhagic fever viruses are needed to prove or
disprove the disease

CCHF IgM/IgG ELISA:

Best to be done at the end of the first week and up (1,4)

Complementary test: In the future we need especially in epidemic and outbreak of

cases dipstick rapid test for CCHF.

CCHF Case Definition:

Table 1 below uses the Score Method for certain variables, which
includes (exposure history, clinical features, lab tests and confirmatory
tests). Cases classified into (4):

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Suspected Case:
The suspected case is defined as the case with a score≥5

Probable Case:
The probable case is defined as the case with a score ≥12

Confirmed:
The confirmed case is defined as the suspected or probable case with
PCR positive or serum sample by ELLISA IgG or IgM Positive

Modified Criteria for Clinical Diagnosis of CCHF (8) Table 1

Item Score
Exposure history 3
- Bitten by ticks / Direct contact
with blood/secretion of livestock or suspected/confirmed CCHF case
- Resident in / visited a rural area where contact with Livestock or ticks was possible, but
a specific exposure cannot be identified 2
Clinical feature
- sudden onset HGF>38.5 c for ≥ 3 days 3
- Headache 1
- Myalgia 1
- Nausea/vomiting 1
- diarrhea 1
- bleeding manifestations 3
Lab. Tests
- Platelet < 100x10 9 2
- Platelet ≥ 100-150x109 1
- WBC (<3 or >11x109) 1
- Abnormal AST >100 U/L 1
- Abnormal ALT >100 U/L 1
- Prolonged PT 1
- Prolonged aPTT 1
Confirmatory tests
A. PCR-CCHF
B. Serum IgM / IgG ELISA
Total 20
Suspected: ≥ 5
Probable ≥12
Confirmed: probable +PCR/IgM ELISA
CCHF: Crimean Congo Hemorrhagic Fever, HGF: High-grade fever
A score of 12 points or more indicates treatment as a case of CCHF.

12
 CCHF prognostic indicators:
The confirmed cases and according to clinical scoring as in Table 2 below using certain clinical and
Lab variables are subdivided into (5):
Mild:
A mild Case is a case with a score < 5
Moderate:
Moderate Case is a case with a score of 5 -9
Severe/life-threatening:
A severe/life-threatening case is a case with a score≥10

Table 2 modified clinical severity scoring system (MCSSS) for CCHF. (7,8)
Item Classification CSS
Clinical data: No
Bleeding 0
Petechia 1
Ecchymosis 2
Bleeding 3
Neuropsychiatric* NO 0
YES 3
Pulmonary* NO 0
YES 3
Shock* status/MOF NO 0
YES 3
Lab data: >100x10*9 0
DIC score 50-100x10*9 1
Platelet <50x10*9 2
normal 0
PT Prolonged 1
normal 0
aPTT prolonged 1

WBC <10.000x109 0
>10.000 x109 1
AST <5ULN 0
≥ 5 ULN 1
ALT <1ULN 0
≥1ULN 1
TSB <5 mg/dl 0
≥5 mg/dl 1
Total 20
Mild: <5
20
Moderate:5-9
Severe/life threatening: ≥10

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MOF: multi-organ failure, ULN: upper limit of normal, CSS: clinical severity score
*Presence of one of these clinical complications makes the case severe regardless score point
Neuropsychiatric: agitation, irritability, hallucination, seizure, DLOC, coma, ICH
Pulmonary: hypoxia, ARDS, Pulmonary infiltration, pulmonary hemorrhage.

Infection prevention and control (IPC). (1)

1.IPC is essential for all – care provider, patients,

family, and community
2.Use appropriate PPE as determined by risk
assessment.
3.Enhanced precautions are always in addition to
standard precautions.
4.enhanced collaboration between the directorates of
health, environment and veterinary to approach
the patients in addition to the infectious agents,
vectors and hosts.

Standard Precautions
All patients, all the time
“Standard precautions are meant to reduce the risk
of transmission of blood-borne and other pathogens from
both recognized and unrecognized sources.

They are the basic level of infection control

precautions which are to be used, as a minimum, in all
patient care settings."

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Components of Standard Precautions (1)
•Hand hygiene
•Assess all health-care activities to determine the personal protection that
is indicated (gloves, facial protection, and gown) depending on the
anticipated exposure
•Prevention of needle stick and injuries from other sharp instruments
•Respiratory & cough hygiene
•Environmental cleaning
•Patient care equipment (clean, disinfect, and reprocess reusable
equipment appropriately before use with another patient)
•Safely handle linens
•Safe waste management.

Patients’ management:
General:
Patients with probable or confirmed CCHF should be isolated and cared
for using strict barrier-nursing techniques – masks, goggles, gloves,
gowns and proper removal and disposal of contaminated articles.
Only designated medical / para-medical staff and attendants should
attend the patient.
All medical and para-medical staff and attendants should wear
disposable gloves
disposable masks and gowns on entering room, remove on exiting,
and disposed articles completely incinerated.(1,3,4)

Patients are not allowed to leave the hospital under any



circumstances unless the patient is cured because of the risk of

disease transmission to the community.
The asymptomatic cases can be managed at home with careful


home isolation and close follow-up of the general condition and

temperature for two weeks.
Avoid intramuscular injection to avoid hematoma locally.


Avoid unnecessary procedures or invasive interventions.



15
 Avoid anti-platelet, Anticoagulant and non-steroid anti-
inflammatory drugs to decrease the systemic bleeding tendency
(1,4).
Proton pump inhibitors may be used to prevent gastrointestinal
bleeding, which may occur due to either disease complications or
stress (8).
In women, inhibition of menstrual bleeding by
administering progesterone may be indicated (4).
Iv haloperidol may be used in ameliorating acute agitation
complicating CCHF.
RCU admission with assisted ventilatory support may be needed in
pulmonary complications with respiratory failure.

Specific:
In the Viremia phase:
All supportive care must be done, including bed rest ,antipyretics for fever, and
IV. Fluid in case of Hypotension or Dehydration, Antibiotics for secondary
bacterial infection or leucopenia impending bacterial infection or in case of high
dose Steroid is used). Correction of electrolyte disturbance with nutritional support
of the patients.

In the hemorrhagic phase:

Platelet transfusion:

• When there is a plt. count< 50x109, and there is bleeding diathesis or

requiring surgical intervention (8).

• If plt. count<20x109 with fever or clotting abnormality (8).

• If plt. count less than 10x109 (7).

• (Platelet dose 0.1 units/ kg/day). The platelet is either a random donor or,
preferably an apheresis single donor where each apheresis unit equals 4-6
units of random donor plts (8)

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Fresh Frozen Plasma:

• It is used in case of DIC, massive hemorrhage, liver-failure, vitamin K

deficiency, if INR>1.5 times above average; the dose infused 10-15 ml/kg
(8).

Cryoprecipitate:
It's used in the case of hypofibrinogenemia.

Ribavirin:
Ribavirin should be started as early as possible to treat suspected CCHF cases,
even before the result of PCR.

It is found in IV and oral formulations. IV Infusion 30 mg per kg maximum 2 grams

loading dose then followed by 15 mg per Kg maximum 1 gm every 6 Hours for
four days followed by 7.5 mg/kg (maximum 500 mg) every 8 hours for six days.
The drug should be diluted in 150ml of normal saline 0.9% infused slowly, the
dose reduced in cases of renal insufficiency when creatinine clearance is less
than 50 ml/Day. It is avoided in pregnancy and breastfeeding. Its side effects are
fatigue, nausea/vomiting, hemolytic anemia, pancreatitis, and pancytopenia, it is
teratogenic, and both parents should use contraception for six months later (8).

Corticosteroids:
Corticosteroid is used in severe and life-threatening conditions with severe
thrombocytopenia when plt<50x109 in the form of high dose methyl prednisolone
(HDMP) 10-15 mg per Kg maximum 1g for 3-5 days with strict glycemic and blood
pressure control (8).

IV IMMUNOGLOBULIN (IVIG):
It can be used in refractory severe thrombocytopenia (8)

Convalescent plasma therapy:

It needs to be studied thoroughly in the future using randomized control trials
(8)

Favipravir tablets& Chloroquine:

They need to be studied in the future using randomized control trials (8).

CCHF hyperimmunoglobulin:
It needs to be studied in the future using randomized control trials (10).

17
Vaccine:
It is our future target we should insist on it every time(11).
‹#›
CCHF pregnancy management (4):

management
Apply appropriate IPC measures at all times when caring for pregnant
women and during delivery.
Before delivery: monitor fetus on admission and at least twice daily.
Evaluate for co-infection, such as urinary tract infection. Treat empirically
with appropriate antimicrobials. Ribavirin should be avoided till randomized
control trials prove its efficacy. Provide supportive care as necessary.
During labour: safe management of labour and delivery by expert
multidisciplinary team.
•Unviable fetus: A pregnant woman with CCHF who has an unviable fetus
should have an immediate evacuation of dead fetus. After evacuation,
ensure there are no retained products of conception.
•Viable fetus: if the mother improves clinically, a normal vaginal delivery is
possible. If the mother continues to be ill, treatments can be extended.
Safe management of labor, including timing and method of delivery, should
be based on fetal maturity, mother’s severity of illness and presence of
fetal distress
After delivery: test the newborn and maternal breast milk immediately for
CCHF virus. Monitor newborn carefully for development of signs or
symptoms of CCHF/sepsis, re-test if indicated

Management of complications m anagement of com

Pulmonary complications: airway management, high flow oxygen therapy
and, in certain cases, intubation followed by lung protective ventilation.
•Encephalopathy: recognize neurologic emergencies, place IV, correct
glucose, and electrolyte abnormalities, treat seizures if present, correct
shock with oxygen/crystalloid fluids +/- vasopressors and avoid
unnecessary sedatives.
•Seizure: Always treat the underlying cause and provide supportive care.
Exercise caution when treating a patient with active seizure as performing
18
 injections and/or placing an IV can pose risks to the provider and the
patient if the patient is actively moving.
•Acute kidney injury: recognize AKI, place IV, correct shock with
oxygen/crystalloid fluids +/- vasopressors, avoid nephrotoxic agents,
correct electrolyte disorders, and consider dialysis.

Infectivity period:
Infectivity parallels the clinical state. Persons are most infectious late in the course
of the severe disease when viral loads are high, and patients shed the virus to the
environment through vomiting, diarrhea, and bleeding. The risk of transmission
during the incubation period and from the asymptomatic patient is negligible.

Follow on patient care and recovery: We need a one-week-temperature follow-up

after the cure; if normal, the patient can be considered non-infectious proved by
PCR-CCHF(-ve).

The virus has vertical transmission, is not transmitted by breastfeeding, and not proved
sexually transmitted disease, although it is found in urine, so best to wait two weeks
after the cure and then can practice sex.

(4)

Infection prevention and control precautions in the healthcare setting: may occur in the
medical staff career of the patient. We can use oral Ribavirin to contact patients with
19
CCHF patients, with patient monitor by clinical follow up with temperature study daily
and investigate the patients after two weeks. If temperature normal and CCHF PCR are
negative, they are considered normal (1,4).

Prophylaxis Protocol:
In case of known direct contact with the blood or secretions of a probable or confirmed
case such as needle stick injury or contact with mucous membranes such as eye or
mouth, do baseline blood studies and then start the person on the Ribavirin therapeutic
protocol.

Households or other contacts of the case who may have had the same exposure to
infected ticks or animals or who recall indirect contact with case body fluids should be
monitored for 14 days from the last contact with the patient or other source of infection
by taking the temperature twice Daily. If the patient develops a temperature of 38.5° C
or more significantly, headache and muscle pains, they would be a probable case. They
should be admitted to the hospital and started on Ribavirin treatment as mentioned
above and sent for PCR-CCHF (12).

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 CCHF Follow-up case sheet:
Figure 3 below shows the CCHF follow-up case sheet with the required data

Figure 3
21
Discharging Criteria:
Figure 4 below illustrates the criteria for discharging CCHF patients from the hospital
Criterion Description
Clinical improvement and absence of symptoms, hemorrhagic
1 Clinical Criteria
complications for at least 2 – 3 days
A. Platelet > 50 x 109 /Litter of blood
2 Lab Criteria B. Normalization of coagulation cascade
C. Descending curves of liver transaminases

References:
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