Crimean-Congo haemorrhagic fever in Spain

Advice for travellers following confirmation of a case of CCHF in Spain

On 27 April 2024, the Castile and León Ministry of Health reported a confirmed case of Crimean-Congo haemorrhagic fever (CCHF) in Salamanca province, Castile-León, north-western Spain [1]. The first official locally acquired case of CCHF in Spain was reported in 2016 in the province of Avila, Castile-León [2]. According to European Centre for Disease Control, in Europe from 2013 to date, 13 cases have been reported from 3 provinces in Spain, 33 cases from Bulgaria and one from Greece (see map).

CCHF is endemic throughout Africa, the Balkans, the Middle East, western and south-central Asia, and Eastern Europe. The CCHF virus is transmitted to humans by the Hyalomma tick [4] or through direct contact with blood, tissues, secretions or bodily fluids of infected animals and humans.

Most cases occur in people living in tick-infested areas with occupational exposure to livestock including farmers, slaughterhouse staff and vets. Exposure to the virus may also occur from contamination with tick body contents/blood, for example, if a tick is squashed between the fingers [2, 4]. Cases have been reported in health workers caring for infected people [2].

Outdoor activities in endemic areas are a risk factor for tick exposure [2].

Most people infected with the virus have no symptoms or experience a mild illness [2]. Early symptoms include fever, muscle aches, dizziness, headache, sore eyes, and photophobia (light sensitivity). Nausea, vomiting, diarrhoea, abdominal pain, and sore throat, followed by sharp mood swings and confusion can occur. Sleepiness, depression, and lethargy may follow. [2, 4].

Other clinical signs can include a fast heart rate (tachycardia), enlarged lymph nodes, a rash on the skin or in the mouth and throat, kidney, liver or lung failure. Reported case fatality rates during outbreaks range from 5 to 40 percent [2].

CCHF is not present in the United Kingdom (UK), nor are there any identified established populations of Hyalomma ticks.

Advice for travellers

Before you travel

Check and follow the advice from the Foreign, Commonwealth & Development Office on safety, security, and any travel restrictions at your destination.

Check our Country Information pages to research general health risks, prevention advice and any vaccine recommendations or malaria advice for your destination. Cases of CCHF may be reported on our Outbreak Surveillance database.

There is no licensed vaccine to prevent CCHF [2].

While you are away

The risk of contracting CCHF for travellers in endemic areas is mainly related to tick bite exposure during outdoor activities. For most UK travellers visiting Spain, the risk is very low if precautions are followed. You can reduce your risk of infection with the following measures [4]:

• avoid areas where ticks are abundant at seasons when they are most active (Spring to late Autumn)
• use tick repellents and wear long sleeved clothing / socks
• check clothes and skin carefully for ticks and remove them with a recommended technique - see our insect and tick bite avoidance factsheet for details.
• if working with animals in endemic areas, use tick repellents on skin and clothing, and wear gloves/protective clothing to prevent skin coming into contact with infected tissues/blood [4].

When you return

If you or anyone in your family become unwell with symptoms such as a high fever, muscle aches, dizziness, headache or sore eyes within 14 days of your return from a country with a risk of CCHF, you should seek medical advice. It is important to tell your medical provider about any recent travel.

Advice for health professionals

Health professionals should remain alert for travellers returning from CCHF affected areas who develop symptoms compatible with CCHF.

Health professionals should practise strict infection control precautions, including barrier nursing, when caring for patients with relevant travel history and any symptoms suggestive of viral haemorrhagic fever [6].

Guidance on the management of viral haemorrhagic fevers and similar human infections of high consequence is available from the Advisory Committee on Dangerous Pathogens (ACDP) [6].

There are specialised laboratory facilities in the UK to provide a definitive CCHF diagnosis. After discussion with their local microbiology, virology, or infectious disease consultant, health professionals can contact the Imported Fever Service (IFS) for advice and to arrange testing if indicated.

Health professionals seeking information about testing samples from patients with a possible viral haemorrhagic fever should read Viral haemorrhagic fever: sample testing advice before contacting the IFS.