Page 94 - JSOM Spring 2023

An Ongoing Series

Crimean-Congo Hemorrhagic Fever

A Refresher and Update for the SOF Provider

Justin Klucher, MD ; Adam Gonzalez, 18D ; Akira A. Shishido, MD *
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ABSTRACT
Crimean-Congo Hemorrhagic Fever (CCHF) is the most wide- endemic to that region. Additionally, the US Centers for Dis-
spread tickborne virus causing human disease. CCHF wields ease Control (CDC) and US Army Medical Research Institute
a mortality rate up to 30% and was responsible for the death for Infectious Diseases (USAMRIID) list CCHF as a Category
of a US Soldier in 2009. The virus is spread by the Hyalomma A Bioagent. This review serves as a refresher and update of
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species of hard tick found across Central Europe, the Middle the epidemiology, clinical disease, and management of CCHF
East, Africa, and Asia south of the 50° parallel. Infection typ- to include recent breakthroughs in experimental therapeutics
ically consists of a 1–7-day non-specific viral prodrome, fol- for the SOF provider.
lowed by onset of hemorrhagic disease on days 7–10. Severe
disease may cause thrombocytopenia, transaminitis, petechial Military History
hemorrhage, hematemesis, and death typically by day 10 of
illness. Education and insect control are paramount to dis- Early descriptions in ancient Tajiki medical texts describe a
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ease prevention. Treatment is predominantly supportive care, deadly hemorrhagic disease that is now suspected to be CCHF.
though evidence suggests a benefit of early ribavirin adminis- The first modern reports of the disease emerged in 1944 when
tration. CCHF has caused multiple nosocomial outbreaks, and 200 Soviet military personnel were infected while aiding peas-
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therefore consideration should be given to safe transport and ants in the war-devastated region of Crimea. Russian scientist
evacuation of infected and exposed patients. Given the wide M.P. Chumakov first identified the viral nature of the agent by
area of distribution, transmissibility, innocuous arthropod infecting human subjects with a filtered suspension of ticks.
vectors, and high mortality rate, it is imperative that Special He later isolated the virus in mice in 1967. 2,6,7 In Africa, a dis-
Operations Forces (SOF) providers be aware of CCHF and the ease named “Congo Virus” under active investigation with no
existing countermeasures. link to Chumakov’s research was found to be caused by the
very same pathogen. 2,6,7 The causative agent was subsequently
Keywords: Military medicine; bioagent; zoonosis; tickborne named Crimean-Congo Hemorrhagic Fever Virus, thus linking
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diseases its demographic distribution. Since that time, multiple out-
breaks and cases have been reported throughout Africa and
Eurasia. In 2009, a US Soldier contracted the disease while
stationed in Afghanistan. The soldier was evacuated to Land-
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Introduction
stuhl Regional Medical Center in Germany but expired on day
CCHF is a deadly tickborne illness caused by a Nairovirus 11 of illness. Two healthcare workers were also infected but
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of the same name (CCHFV). First discovered in the Crimean developed only mild symptoms after treatment with ribavirin. 4
Peninsula in 1944, CCHF is now known to be endemic
throughout regions of Africa, the Middle East and Eurasia. Epidemiology and Transmission
CCHF has the most wide-spread geographical distribution
of all tickborne viruses that cause human disease and is sec- Ticks of the genus Hyalomma (family Ixodidae) are the princi-
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ond only to Dengue virus in distribution among arbovi- pal reservoir and vector of CCHFV (Figure 1). The geographic
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ruses. CCHF carries a high mortality rate estimated between distribution of the disease follows countries with a Hyalomma
5–30%, and was responsible for the death of a US Soldier in tick vector presence. This includes Europe, the Middle East,
2009. Given the recent focus on the military proceedings Africa, and Asia, specifically in countries south of the 50° par-
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between Ukraine and the Russian Federation, SOF medical allel north (Figure 2). Based on this distribution, the World
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providers should be increasingly aware of the medical threats Health Organization (WHO) estimates that approximately
*Correspondence to akira.shishido@vcuhealth.org
1 Dr Justin Klucher is a physician affiliated with the Department of Medicine, University of Maryland Medical Center, Baltimore, MD. Adam
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Gonzalez is an 18 Delta affiliated with the 19th Special Forces Group (Airborne), Buckley Armory, WA. Dr Akira A. Shisido is a physician affil-
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iated with the Division of Infectious Diseases, Virginia Commonwealth University Hospital, Richmond, VA.
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