The Ministry of Health has confirmed two new cases of Crimean-Congo hemorrhagic fever (FHCC) in two men —one of them deceased— residing in the Bierzo region (León)according to a new report prepared by the Center for the Coordination of Health Alerts and Emergencies.
The first case, a 49-year-old hunter, with a history of tick bite, began symptoms on July 12 and is in stable condition. The second case, aged 51, was retrospectively diagnosed on July 20, after having died on June 19 for an unknown cause with suspected poisoning by sulfur compounds.
Between 2013 and 2022, a total of 12 cases with 4 deaths have been confirmed in Spain: one in 2013 in Ávila, two in 2016 —one of them in Ávila and a secondary case in a health worker—, two in 2018 in Badajoz and Salamanca, three in 2020 in Salamanca, two in 2021 in Salamanca and León (el Bierzo) and the two that have just been published, corresponding to 2022 and produced in El Bierzo.
It is not the first time that it has been detected in El Bierzo. On June 10, 2021, another case was confirmed in a woman resident in El Bierzo who had also been in some places of Ourense, around the Ribera Sacra, Galicia. However, Health affirms that the “risk is moderate” in this area.
“The risk of transmission of the CCHF virus (CCHFV) in the Comarca del Bierzo, as in the rest of the areas where circulation of the virus has been evidenced in ticks, animals or human cases have been detected, is moderate, especially in the population with a higher exposure to tick bites —people in contact with animals or who carry out outdoor activities in the countryside—”, the report states.
For the rest of Spain, the risk is considered “low”although remember that it is conditioned to the activity of the vectors, whose activity is maximum in the summer season.
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VFHCC was identified for the first time in Spain in 2010, in ticks captured on deer from a hunting estate in Cáceres, on the banks of the Tagus River on the Portuguese border. A subsequent study carried out in various areas of the country, in different species of ticks (2,053) obtained from livestock and vegetation and sera from people exposed to ticks in Cáceres (114) and La Rioja (114), did not show the presence of the virus in any sample.
In another study carried out between 2011 and 2015, 1,579 ticks were captured on wild and domestic ungulates in Cáceres, Toledo, Segovia and Huesca. Given the detection of the first two human cases of CCHF in 2016, a three-phase study was launched to assess the situation and risk of CCHFV infection in Spain.
two new cases
According to the report, on July 18, Castilla y León informed the Center for the Coordination of Health Alerts and Emergencies and the National Center for Epidemiology a suspected CCHF.
It was a 49-year-old man, hunter, resident in Ponferrada (Comarca del Bierzo, León) with a history of tick bites that on July 12 began with gastrointestinal symptoms (abdominal pain, diarrhea, and vomiting) along with headache and fever.
On July 16, he was hospitalized with elevated transaminases and thrombocytopenia. And on July 19, the National Center for Microbiology (CNM) confirmed by real-time PCR the positivity against CCHFV. The case was transferred on July 20 to the high-level isolation unit in Donostia, where it is evolving favorably.
Regarding the second case, Health reported that on July 20 the National Institute of Toxicology and Forensic Sciences sent the CNM blood samples from a 51-year-old man, an environmental agent, who He had died on June 19, 2022 at the Hospital del Bierzo, León, with probable diagnosis of 20% cuprocalcium sulfate intoxication, hemorrhagic shock and coagulopathy.
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Real-time PCR was positive against CCHFV in blood. The case did not refer to a history of tick bite, but he had been sulfating his orchard and symptoms began 24 hours later. He was initially diagnosed with a respiratory infection with headache.; subsequently he developed abdominal discomfort, diarrhea and on June 16 he was admitted with severe coagulopathy, experiencing progressive deterioration until his death 3 days later.
As a consequence of this case, four close contacts were identified who performed the autopsy and another four who handled the samples in the laboratory. Currently, follow-up has been completed with no secondary cases detected.
What is the FHCC?
CCHF is one of the most widespread tick-borne diseases worldwide, affecting population from various parts of Africa, Asia, Eastern Europe and the Middle East. The disease-producing agent is CCHFV, transmitted by the bite of hard ticks (Ixodidae), mainly of the genus Hyalomma.
Human beings can be infected by the bite of the tick, which also acts as a reservoir, or by direct contact with secretions or fluids of an infected animal host during the acute phase.
There may be person-to-person transmission by direct contact with blood, secretions, other body fluids, or aerosols of infected individuals or with contaminated inanimate objects, which occurs more frequently in health personnel, although some studies indicate that this transmission with adequate protection measures is infrequent.
After an incubation period of 5 to 6 days, most symptomatic cases present a mild clinic of 4 to 5 days of evolution characterized by fever, headache, myalgia and dizziness.
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In a few cases, the disease progresses to a severe clinical picture with hemorrhagic manifestations in the skin and mucous membranes, such as petechiae or bleedingwhich can progress to death.
The fatality rate ranges from 3% to 40%, depending on the studies. Serological studies conducted in endemic countries indicate that infection in humans can be asymptomatic, although it is difficult to establish what percentage. It is unknown whether the infection produces immunity against the virus, although no cases of reinfection with CCHFV have been identified.
Diagnosis is made by virus isolation, genome detection by PCR (specific, sensitive and rapid method) or serology (IgM and IgG antibodies are detected by ELISA and immunofluorescence assays from about 7 days after the onset of the disease). There is no vaccine for this disease and no specific treatmentalthough ribavirin has been used with apparent beneficial effect.
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