Episode 1

In 2005, CCHFV infection was diagnosed in a woman on the day of delivery by cesarean section. She was transferred to IDCM, and her baby was transferred to the newborn service at the Dr. Sami Ulus Children's Hospital (Ankara, Turkey). A nurse in IDCM, who had fever and myalgia, was later found to have CCHFV infection (Table 1). Transmission was related to the improper use of gloves during the care of the mother’s surgical wound. The mother recovered, but the infant died 5 days after birth. A nurse in the neonatal clinic in the children’s hospital also acquired CCHFV infection, which was attributed to the intubation and aspiration of bloody secretions from the baby without proper use of gloves and mask. For both HCWs, the incubation period was 2 days. The first HCW was given ribavirin at symptom onset. The second nurse’s illness was mild; because she had a potential for getting pregnant, ribavirin was not started. Both nurses recovered completely (Table 2).

After this episode, the index patient’s contacts were traced. Serum samples from 37 HCWs at IDCM and the obstetrics and newborn clinics at the children’s hospital who were at risk for infection were investigated for CCHF. In addition to the 2 nurses, 2 nurses from the neonatal clinic were CCHF IgM positive but were asymptomatic.

Episode 2

In 2006, a nurse received a needlestick injury during a phlebotomy of a CCHFV-infected patient. She was using gloves but no gown, and the needle stuck to her forearm. The infected patient died. The nurse’s symptoms began 2 days after the incident, and she was transferred to IDCM 4 days after the incident. At admission, her severity score index was high. She had ecchymosis, epistaxis, hematemesis, melena, vaginal bleeding, and somnolence (Table 1). She received oral ribavirin 5 days after the incident, which possibly had limited effect because her illness already had progressed to confusion and gastrointestinal bleeding. She died on the second day after hospital admission.

Episode 3

In 2008, a patient with CCHFV infection and a high viral load (10⁸ copies/mL) was hospitalized with hemoptysis, hematemesis, melena, epistaxis, and intraalveolar bleeding. He died 3 days after admission. One infectious diseases resident and 2 otorhinolaryngology residents acquired CCHFV infection. All HCWs had worn personal protective equipment during the intervention. One otorhinolaryngology resident performed nasal tamponade. After the intervention, the other otorhinolaryngology resident handled and cleaned a head mirror without using gloves, although he was not in face-to-face contact with the patient. The infectious diseases resident resuscitated the patient without apparent direct contact with the patient’s bloody secretions. For the 3 residents, fever, malaise, and myalgia developed 2–5 days after exposure. Ribavirin was started at symptom onset. No contact was observed between the patient and the HCWs, but the RNA sequences from the patients and HCWs were identical by molecular techniques. All of the HCWs recovered.

The transmission of CCHFV could have resulted from indirect contact with contaminated devices, such as the head mirror; the improper removal of gowns, masks, gloves; inadequate hand hygiene; or failure to use N95 masks during aerosolizing procedures. During the procedures that could generate aerosols, HCWs should wear an N95 mask or FFP2 respirator (13). The patients with higher viral load were reported to be more severe disease (14).

Episode 4

In 2008, a phlebotomist working in a children’s hospital had a needlestick injury during phlebotomy of a CCHFV-infected child. He was hospitalized 1 day after symptom onset, and ribavirin was started. His severity score index was moderate, and he recovered.

Episodes 5 and 6

A nurse in 2007 and a pediatric resident in 2008 incurred needlestick injuries during phlebotomy of a CCHFV-infected patient. Postexposure prophylaxis with ribavirin was started immediately after the injuries, and no infections developed.