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WHO EMRO Weekly Epidemiological Monitor: Volume 14, Issue no 5; 31 January 2021

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Current major event

Crimean-Congo haemorrhagic fever (CCHF) in Afghanistan: Year 2020

As of epidemiological week 53 of 2020, a total 184 cases of CCHF, including 15 deaths (CFR 8.2%) were reported by the National Disease Surveillance and Response (NDSR) system of Afghanistan. Of all reported cases, 81 were clinically diagnosed while 103 tested positive for CCHF by PCR testing.

Editorial note

Crimean-Congo haemorrhagic fever (CCHF) is an acute zoonotic disease caused by a tickborne virus (Nairovirus) transmitted through contact with infected ticks or animal blood, human-to-human contact (through infectious blood or body fluids), or the use of improperly sterilized medical equipment and supplies. The disease has haemorrhagic manifestations with considerable mortality in humans. Major complications of CCHF include hepatitis, rapid kidney deterioration, sudden liver failure or pulmonary failure which may lead to death (CFR up to 30%).

CCHF trends in Afghanistan have been steadily increasing since 2013 (when 45 cases were reported), with upsurges in 2018 (483 cases) and 2019 (583 cases), partly explained by the enhancement of surveillance systems and improved reporting. A sharp drop followed in 2020 when 184 cases were reported including 15 deaths (see table).

Geographically, 27 out of 34 provinces in Afghanistan reported CCHF cases in 2020, with the most affected provinces being Kabul (53 cases, 4 deaths), Herat (37 cases, 6 deaths) and Balkh (17 cases, no deaths).

CCHF is known to be endemic to Afghanistan, particularly in the areas bordering Islamic Republic of Iran and Pakistan where there is high cross-border movement of nomadic communities and their animals. CCHF was continually reported in the country during 2020 with a noted increase starting during week 31 (early August) and progressing to peak between weeks 39 to 47 (October to November). Increase in cases has usually been noted to correspond to the months when livestock movement is at its peak throughout the country (see graph).

The Ministry of Public Health continues to lead and involve other stakeholders in response activities. These include enhancing surveillance through the daily reporting of cases and deaths, conducting trainings for rapid response teams with a focus on CCHF, and distributing communication materials in high risk provinces. An accelerated response plan was implemented following its development in 2019, and coordination among the human and animal sectors was enhanced.

However, insufficient resources being allocated for tick control across the country posed as a challenge for the response, and only passive, inadequate disease surveillance was conducted by the animal sector. But the ministry has identified a way forward to mobilize adequate resources for the implementation of the national response plan, build capacity for genotyping and sequencing of the CCHF virus, and conduct continuous training of health care workers on prevention, control and case management of CCHF.

WHO recommends implementing leadership, coordination and joint national planning using the ‘One-health’ approach where multiple sectors such as animal health, agriculture, environment, veterinary services, and researchers actively collaborate to enhance long-term efforts to control CCHF as well as other zoonotic diseases. Additionally, preventive and control strategies in the animal sector should be implemented including the building of national capacities in animal health, improving skills to address health problems at the animal-human-environment interface, integrating surveillance of zoonotic diseases, and supporting joint risk assessments, outbreak investigations and control, as well as cross-border collaboration and information sharing