Crimean-Congo Hemorrhagic Fever, Herat Province, Afghanistan, 2017

We studied the clinical and epidemiologic features of an outbreak of Crimean-Congo hemorrhagic fever in Herat Province, Afghanistan. The study comprised 63 patients hospitalized in 2017. The overall case-fatality rate was 22.2%; fatal outcome was significantly associated with a negative IgM test result, longer prothrombin time, and nausea.

We studied the clinical and epidemiologic features of an outbreak of Crimean-Congo hemorrhagic fever in Herat Province, Afghanistan. The study comprised 63 patients hospitalized in 2017. The overall case-fatality rate was 22.2%; fatal outcome was significantly associated with a negative IgM test result, longer prothrombin time, and nausea. C rimean-Congo hemorrhagic fever (CCHF) is a geographically widespread tickborne disease caused by the CCHF virus (genus Orthonairovirus, family Nairoviridae). In humans, CCHF is associated with a case-fatality rate (CFR) of 5%-50% (1) and is considered a major public health threat (2).
CCHF A descriptive case series study at Herat Regional Hospital during January-December 2017 was undertaken. Clinical and epidemiologic features of all confirmed and probable CCHF cases were recorded. The Human Ethics Committee of Herat University approved the study protocol (approval #0317).
The most frequent clinical manifestations were fever, headache, and myalgia, and the most common hemorrhagic manifestations were ecchymosis, epistaxis, and hemoptysis. At admission, all patients had thrombocytopenia, and 62 (98.4%) had leukopenia. Aspartate aminotransferase and alanine aminotransferase levels were elevated in 43 (68.3%) patients. PT time was longer than normal in 29 (46.0%) and activated partial thromboplastin in 23 (36.5%) patients (Table).
A previous study established that CCHF patients who die rarely mount a detectable IgM response, and laboratory diagnosis should therefore include reverse transcription PCR (8). A positive association of death with longer PT also has been previously described (9). A new finding from this study was the association between fatal outcome and nausea.
Our findings are important for persons in Afghanistan, especially in Herat Province, because the study identified demographic variables (age and occupation) that can be further investigated by a risk factor study. Our findings also are important for persons traveling to Herat Province. Only 1 CCHF case has thus far been reported in a tourist returning home from northwestern Afghanistan, where the disease was acquired (10). Our findings can also be used to refine the CCHF case definition for improved clinical awareness in Afghanistan.
Our study demonstrates that Herat Province remains the endemic focus of CCHF in Afghanistan, and the number of cases is increasing over time. Control and mitigation measures implemented for CCHF in Herat have not been successful in containing this fatal disease. Considering the major social and economic consequences and the health burden CCHF places on the community, alternative or enhanced public health measures, including improved surveillance and risk communication, are necessary to control CCHF in Herat and neighboring provinces. Our findings might serve as a template and reference for future CCHF surveillance activities in this region.

About the Author
Dr. Niazi is head of the Department of Public Health and Infectious Diseases in the Faculty of Medicine, Herat University. His primary research interests include public health and emerging infectious diseases, with a focus on vectorborne viral diseases.