Molecular (ticks) and serological (humans) study of Crimean-Congo hemorrhagic fever virus in the Iberian Peninsula, 2013-2015

Identification, Characterization, and Homology Analysis of a Novel Strain of the Crimean-Congo Hemorrhagic Fever Virus from Yunnan, China

Wildlife serve as potential microbial reservoirs, accounting for approximately 70% of emerging infectious diseases. Crimean-Congo hemorrhagic fever virus (CCHFV), which causes Crimean-Congo hemorrhagic fever (CCHF) in humans, is a highly pathogenic tick-borne virus prevalent in several parts of Asia, Africa, and Europe with high case fatality rates. Several CCHFV cases have been reported in Asia, the Middle East, Africa, and Southern and Eastern Europe. The disease is endemic in several parts of western China, particularly Xinjiang. Ticks of the genus Hyalomma have been identified as a principal vector and reservoir for CCHFV, although other tick species may also have a crucial role in maintaining CCHFV in endemic regions. On infection, CCHF begins as a nonspecific febrile illness that can progress to severe hemorrhagic manifestations with a higher case fatality due to the unavailability of vaccines or other therapeutic agents. In this study, we collected tissue samples from a wild dead Chinese serow (Capricornis milneedwardsii) and three Naemorhedus griseuses from Deqin County, Tibetan Autonomous Prefecture, Yunnan, China, to investigate for contagious viruses that could be transmitted to humans. We identified a novel CCHFV strain, YNDQL-415G, in the liver tissue of a dead C. milneedwardsii. We performed nucleotide and amino acid sequence homology on the full-length viral genome. The results revealed significant homology between the viral S segment to that of the Africa1 strain, while the M and L segments showed similarity with the Asia CCHFV strain, indicating potential gene reassortment in the YNDQL-415G strain. The genetic characterization of a novel CCHFV strain from a dead C. milneedwardsii raises concerns about the possibility of a new zoonotic infection. A regular survey program is recommended to track the distribution of wild animals as well as the viruses they may transmit to humans and other domestic mammals in the region.

Tick-borne pathogens in ticks from urban and suburban areas of north-western Spain: Importance of Ixodes frontalis harbouring zoonotic pathogens

To identify the questing tick populations in urban and suburban areas from the city of Lugo (NW Spain), ticks were collected monthly by flagging. The presence of Borrelia spp., Rickettsia spp. and Anaplasma phagocytophilum also was determined by polymerase chain reaction (PCR) and sequence analysis. Overall, 342 questing ticks were collected; the tick abundance was higher in suburban (95.9%) than in urban areas (4.1%). Ixodes frontalis was the most abundant (86.5%); 88.5% were larvae, 11.1% nymphs and 0.3% adults. All development stages of I. ricinus (7.3%) and adults of Rhipicephalus sanguineus sensu lato (5.8%) and Dermacentor reticulatus (0.3%) were found. Rickettsia spp. (31.9%) was more prevalent than Borrelia spp. (2.7%); no ticks were positive to A. phagocytophilum. Six Rickettsia species were identified (R. slovaca, R. monacensis, R. massiliae, R. raoultii, R. sibirica subsp. mongolitimonae and R. aeschielmanii); Candidatus Rickettsia rioja and two novel Rickettsia species also were detected. In addition, Borrelia turdi (1.8%) and B. valaisiana (0.9%) were identified in Ixodes ticks. This is the first report of R. slovaca in R. sanguineus s.l. and of R. monacensis, R. raoultii, R. slovaca, R. sibirica subsp. mongolitimonae and Ca. R. rioja in I. frontalis. Since most of the pathogens detected are zoonotic, their presence in these areas may have implications for public health.

The spatial pattern of human exposure to Crimean-Congo haemorrhagic fever virus is not consistent with red deer-based risk predictions

The objective of this study was to evaluate the spatial risk of exposure to Crimean-Congo haemorrhagic fever virus (CCHFV) infection of healthy blood donors in an enzootic region with a predicted risk gradient based on a virus-animal interaction risk model. We designed a cross-sectional study to test if the exposure pattern of the human population to CCHFV spatially matches the predicted risk. We randomly selected 1384 donors from different risk gradients and analyzed their sera searching for CCHFV antibodies. None of the selected blood donors showed exposure to CCHFV. This study shows that exposure risk spatial patterns, as predicted from animal-tick-virus models, does not necessarily match the pattern of human-infected tick interactions leading to CCHFV infection and CCHF cases, at least in a region of predicted moderate infection risk. The findings suggest that future studies should bear the potential drivers of tick-human encounter rates into account to more accurately predict risks.

Worldwide epidemiology of Crimean-Congo Hemorrhagic Fever Virus in humans, ticks and other animal species, a systematic review and meta-analysis

There are uncertainties about the global epidemiological data of infections due to Crimean-Congo hemorrhagic fever virus (CCHFV). We estimated the global case fatality rate (CFR) of CCHFV infections and the prevalence of CCHFV in humans, ticks and other animal species. We also explored the socio-demographic and clinical factors that influence these parameters. In this systematic review with meta-analyses we searched publications from database inception to 03rd February 2020 in Pubmed, Scopus, and Global Index Medicus. Studies included in this review provided cross-sectional data on the CFR and/or prevalence of one or more targets used for the detection of CCHFV. Two independent investigators selected studies to be included. Data extraction and risk of bias assessment were conducted independently by all authors. Data collected were analysed using a random effect meta-analysis. In all, 2345 records were found and a total of 312 articles (802 prevalence and/or CFR data) that met the inclusion criteria were retained. The overall CFR was 11.7% (95% CI = 9.1-14.5), 8.0% (95% CI = 1.0-18.9), and 4.7% (95% CI = 0.0-37.6) in humans with acute, recent, and past CCHFV infections respectively. The overall CCHFV acute infections prevalence was 22.5% (95% CI = 15.7-30.1) in humans, 2.1% (95% CI = 1.3-2.9) in ticks, and 4.5% (95% CI = 1.9-7.9) in other animal species. The overall CCHFV recent infections seroprevalence was 11.6% (95% CI = 7.9-16.4) in humans and 0.4% (95% CI = 0.0-2.9) in other animal species. The overall CCHFV past infections seroprevalence was 4.3% (95% CI = 3.3-5.4) in humans and 12.0% (95% CI = 9.9-14.3) in other animal species. CFR was higher in low-income countries, countries in the WHO African, South-East Asia and Eastern Mediterranean regions, in adult and ambulatory patients. CCHFV detection rate in humans were higher in CCHFV suspected cases, healthcare workers, adult and hospitalized patients, ticks of the genus Ornithodoros and Amblyomma and in animals of the orders Perissodactyla and Bucerotiformes. This review highlights a significant disease burden due to CCHFV with a strong disparity according to country income levels, geographic regions, various human categories and tick and other animal species. Preventive measures in the light of these findings are expected.

Epidemiological Aspects of Crimean-Congo Hemorrhagic Fever in Western Europe: What about the Future?

Crimean-Congo hemorrhagic fever virus (CCHFV) is an arthropod-borne virus (arbovirus), mainly transmitted by ticks, belonging to the genus Orthonairovirus (family Nairoviridae, order Bunyavirales). CCHFV causes a potentially severe, or even fatal, human disease, and it is widely distributed in Africa, Asia, eastern Europe and, more recently, in South-western Europe. Until a few years ago, no cases of Crimean-Congo hemorrhagic fever (CCHF) had been reported in western Europe, with the exception of several travel-associated cases. In 2010, the CCHFV was reported for the first time in South-western Europe when viral RNA was obtained from Hyalomma lusitanicum ticks collected from deer in Cáceres (Spain). Migratory birds from Africa harboring CCHFV-infected ticks and flying to Spain appear to have contributed to the establishment of the virus (genotype III, Africa-3) in this country. In addition, the recent findings in a patient and in ticks from deer and wild boar of viral sequences similar to those from eastern Europe (genotype V, Europe-1), raise the possibility of the introduction of CCHFV into Spain through the animal trade, although the arrival by bird routes cannot be ruled out (Africa-4 has been also recently detected). The seropositive rates of animals detected in regions of South-western Spain suggest an established cycle of tick-host-tick in certain areas, and the segment reassortment detected in the sequenced virus from one patient evidences a high ability to adaptation of the virus. Different ixodid tick genera can be vectors and reservoirs of the virus, although Hyalomma spp. are particularly relevant for its maintenance. This tick genus is common in Mediterranean region but it is currently spreading to new areas, partly due to the climate change and movement of livestock or wild animals. Although to a lesser extent, travels with our pets (and their ticks) may be also a factor to be considered. As a consequence, the virus is expanding from the Balkan region to Central Europe and, more recently, to Western Europe where different genotypes are circulating. Thus, seven human cases confirmed by molecular methods have been reported in Spain from 2016 to August 2020, three of them with a fatal outcome. A One Health approach is essential for the surveillance of fauna and vector populations to assess the risk for humans and animals. We discuss the risk of CCHFV causing epidemic outbreaks in Western Europe.

Crimean-Congo Hemorrhagic Fever Virus (CCHFV): A Silent but Widespread Threat

Purpose of Review

This review is aimed at highlighting recent research and articles on the complicated relationship between virus, vector, and host and how biosurveillance at each level informs disease spread and risk.

Recent Findings

While human cases of CCHFV and tick identification in non-endemic areas in 2019–2020 were reported to sites such as ProMed, there is a gap in recent published literature on these and broader CCHFV surveillance efforts from the late 2010s.

Summary

A review of the complex aspects of CCHFV maintenance in the environment coupled with high fatality rate and lack of vaccines and therapeutics warrants the need for a One-Health approach toward detection and increased biosurveillance programs for CCHFV.

Crimean-Congo haemorrhagic fever (CCHF) virus-specific antibody detection in blood donors, Castile-León, Spain, summer 2017 and 2018

BackgroundCrimean-Congo haemorrhagic fever virus (CCHFV) is considered an emerging or even a probable re-emerging pathogen in southern Europe. Presence of this virus had been reported previously in Spain in 2010.AimWe aimed to evaluate the potential circulation of CCHFV in western Spain with a serosurvey in asymptomatic adults (blood donors).MethodsDuring 2017 and 2018, we conducted a CCHFV serosurvey in randomly selected asymptomatic blood donors from western Spain. Three assays using specific IgG antibodies against CCHFV were performed: the VectoCrimea ELISA test, an in-house ELISA and indirect immunofluorescence (EuroImmun) test with glycoprotein and nucleoprotein.ResultsA total of 516 blood donors participated in this cross-sectional study. The majority of the study participants were male (68.4%), and the mean age was 46.3 years. Most of the participants came from rural areas (86.8%) and 68.6% had contact with animals and 20.9% had animal husbandry practices. One in five participants (109/516, 21.1%) were engaged in at-risk professional activities such as agriculture and shepherding, slaughtering, hunting, veterinary and healthcare work (mainly nursing staff and laboratory technicians). A total of 15.3% of the participants were bitten by ticks in the days or months before the date of sampling. We detected anti-CCHFV IgG antibodies with two diagnostic assays in three of the 516 individuals and with one diagnostic assay in six of the 516 individuals.ConclusionSeroprevalence of CCHFV was between 0.58% and 1.16% in Castile-León, Spain. This is the first study in western Spain that showed circulation of CCHFV in healthy people.

Seroprevalence of Crimean-Congo hemorrhagic fever in humans in the World Health Organization European region: A systematic review

BACKGROUND

Crimean-Congo hemorrhagic fever (CCHF) is an emerging infectious disease caused by a Nairovirus. CCHF is a tick-borne disease that is predominantly associated with Hyalomma ticks and have a widespread distribution in Africa, Asia and Europe. CCHF usually presents as a subclinical disease, but in some cases, it may present as a hemorrhagic fever with a high mortality rate. This systematic review of the literature was performed to identify the available evidence on the prevalence of CCHF in the European Region of the World Health Organization, based on seroprevalence (IgG antibodies).

METHODOLOGY

A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement protocol. PubMed, Embase, and the Web of Science were used for the search (up to January 31, 2019), combining the following MeSH terms: ["Crimean-Congo haemorrhagic fever" OR "Crimean-Congo hemorrhagic fever virus" OR "Congo-Crimea" OR "Crimea-Congo"] AND ["Europe"] AND ["epidemiology" OR "seroprevalence"]. The abstracts were screened. Subsequently, full-text articles were selected and reviewed based on the PICOS (Population-Intervention-Comparison-Outcomes-Study type) criteria by two independent reviewers for inclusion in the final analysis. The data were qualitatively synthesized without quantitative pooling due to the heterogeneity in the study populations and methodologies.

PRINCIPAL FINDINGS

Thirty articles (9 from western Europe, 18 from central Europe and 3 from eastern Europe) were included in the analysis. All articles were cross-sectional studies (descriptive studies).

CONCLUSIONS

The highest seroprevalence of CCHF is found in central and eastern European countries. Southern and western Europe countries, such as Greece and Spain, have low levels of endemicity, but the spread of the infection, which is associated with climate change, is a possibility that we should keep in mind. Further studies, especially larger seroprevalence studies in humans and animals, are needed to establish the current status of the CCHF epidemiology and to generate standardized guidelines for action in the region.

Survey of Crimean-Congo Hemorrhagic Fever Enzootic Focus, Spain, 2011-2015

During 2011–2015, we conducted a Crimean-Congo hemorrhagic fever virus (CCHFV) survey in captured ticks that were feeding mainly on wild and domestic ungulates in Spain, where presence of this virus had been reported previously. We detected CCHFV RNA in Hyalomma lusitanicum and H. marginatum ticks for 3 of the 5 years. The rate of infected ticks was 2.78% (44/1,579), which was similar to those for other countries in Europe with endemic foci for CCHFV (Kosovo, Bulgaria, and Albania). These data confirm the established spread of CCHFV into western Europe. Phylogenetic study of the small RNA segment showed Africa-3 clade as the only genotype identified, although we observed cocirculation of genetic variants during 2011 and 2015. We could not rule out genetic reassortments because of lack of sequence data for the medium and large RNA segments of the virus genome.

Crimean-Congo hemorrhagic fever: An update

Crimean-Congo hemorrhagic fever (CCHF) is a severe form of hemorrhagic fever caused by a virus of the genus Nairovirus. The amplifying hosts are various mammal species that remain asymptomatic. Humans are infected by tick bites or contact with animal blood. CCHF has a broad geographic distribution and is endemic in Africa, Asia (in particular the Middle East) and South East Europe. This area has expanded in recent years with two indigenous cases reported in Spain in 2016 and 2018. The incubation period is short with the onset of symptoms in generally less than a week. The initial symptoms are common to other infectious syndromes with fever, headache, myalgia and gastrointestinal symptoms. The hemorrhagic syndrome occurs during a second phase with sometimes major bleeding in and from the mucous membranes and the skin. Strict barrier precautionary measures are required to prevent secondary and nosocomial spread. CCHF may be documented by PCR detection of the virus genome during the first days after the onset of illness, and then by serological testing for IgM antibodies as from the 2nd week after infection. Patient management is mainly based on supportive care. Despite a few encouraging retrospective reports, there is no confirmed evidence that supports the use of ribavirin for curative treatment. Nevertheless, the World Health Organization continues to recommend the use of ribavirin to treat CCHF, considering the limited medical risk related to short-term treatment. The prescription of ribavirin should however be encouraged post-exposure for medical professionals, to prevent secondary infection.

Crimean-Congo hemorrhagic fever (CCHF) seroprevalence: A systematic review and meta-analysis

Crimean-Congo haemorrhagic fever (CCHF) is the most widespread, tick-borne viral disease affecting humans and therefore this paper performed a meta-analysis to highlight seroprevalence features of CCHF in a global context. After a preliminary review of the 396 papers representing areas throughout the world, 206 were selected for detailed meta-analysis. In general the total means of CCHF seroprevalence were, respectively 4.7 and 24.6% for humans and animals; and 17.1, 18.9, 24.3, 29.3 and 27.1% for camels, cattle, goats, sheep and livestock. Statistical analysis revealed a significant difference in seroprevalence between humans and camels (P = 0.043), cattle (P = 0.010), goats (P = 0.015), sheep (P = 0.005) and livestock (P = 0.017). Regionally, there also was a difference between humans, and goats (P = 0.0001), sheep (P = 0.007) and livestock (P = 0.002). Globally, CCHF seroprevalence in at-risk professionals was 7.5 fold greater than in normal humans, while CCHF seroprevalence was 5 fold greater in animals, camels, cattle, goats, sheep and livestock than normal humans. Animal contact, animal husbandry, farming, tick bite history and secretion exposure were the most frequently reported CCHF seropositivity risk factors. This study serves as an important resource for epidemiological discussions related to CCHF and CCHF seroprevalence features, providing specific information in understanding human and animal mean and trend CCHF seroprevalence for different regions of the world and on an aggregate global scale; seroprevalence in at-risk professionals; and total mean and trend CCHF seropositivity involving risk factors.

Rescue of Infectious Recombinant Hazara Nairovirus from cDNA Reveals the Nucleocapsid Protein DQVD Caspase Cleavage Motif Performs an Essential Role other than Cleavage

The Nairoviridae family of the Bunyavirales order comprises tick-borne, trisegmented, negative-strand RNA viruses, with several members being associated with serious or fatal diseases in humans and animals. A notable member is Crimean-Congo hemorrhagic fever virus (CCHFV), which is the most widely distributed tick-borne pathogen and is associated with devastating human disease, with case fatality rates averaging 30%. Hazara virus (HAZV) is closely related to CCHFV, sharing the same serogroup and many structural, biochemical, and cellular properties. To improve understanding of HAZV and nairovirus multiplication cycles, we developed, for the first time, a rescue system permitting efficient recovery of infectious HAZV from cDNA. This system now allows reverse genetic analysis of nairoviruses without the need for high-level biosafety containment, as is required for CCHFV. We used this system to test the importance of a DQVD caspase cleavage site exposed on the apex of the HAZV nucleocapsid protein arm domain that is cleaved during HAZV infection, for which the equivalent DEVD sequence was recently shown to be important for CCHFV growth in tick but not mammalian cells. Infectious HAZV bearing an uncleavable DQVE sequence was rescued and exhibited growth parameters equivalent to those of wild-type virus in both mammalian and tick cells, showing this site was dispensable for virus multiplication. In contrast, substitution of the DQVD motif with the similarly uncleavable AQVA sequence could not be rescued despite repeated efforts. Together, these results highlight the importance of this caspase cleavage site in the HAZV life cycle but reveal the DQVD sequence performs a critical role aside from caspase cleavage.IMPORTANCE HAZV is classified within the Nairoviridae family with CCHFV, which is one of the most lethal human pathogens in existence, requiring the highest biosafety level (BSL) containment (BSL4). In contrast, HAZV is not associated with human disease and thus can be studied using less-restrictive BSL2 protocols. Here, we report a system that is able to rescue HAZV from cDNAs, thus permitting reverse genetic interrogation of the HAZV replication cycle. We used this system to examine the role of a caspase cleavage site, DQVD, within the HAZV nucleocapsid protein that is also conserved in CCHFV. By engineering mutant viruses, we showed caspase cleavage at this site was not required for productive infection and this sequence performs a critical role in the virus life cycle aside from caspase cleavage. This system will accelerate nairovirus research due to its efficiency and utility under amenable BSL2 protocols.

Evaluation of Portal Vein Doppler Findings in Patients with Crimean⁻Congo Hemorrhagic Fever

Background and objectives: In this study, we compare portal vein Doppler ultrasound (US) findings between patients with Crimean-Congo hemorrhagic fever (CCHF) and healthy persons and investigate the practicability of these findings in the prediction of disease severity. Materials and Methods: In this prospective study, portal vein Doppler US was performed in patients diagnosed with CCHF and healthy persons between March 2016 and May 2018. The patients were grouped according to mild-to-moderate and severe progression of CCHF. Liver size, portal vein diameter, portal vein flow rate, spleen volume, and splenic vein diameter were recorded in the patients and healthy controls. Results: Of the 48 patients diagnosed with CCHF, 25 were male. According to the scoring made, 38 patients were evaluated as having mild-to-moderate disease progression, and 10 were evaluated as having severe disease progression. With respect to the Doppler US findings, liver size, spleen volume, portal vein diameter, splenic vein diameter, and portal vein flow rate were significantly higher in the patient group compared with the controls. However, no significant difference was found in these parameters between the severe and mild-to-moderate progression groups. Conclusions: In the evaluation of and follow-up with patients with CCHF, portal vein Doppler US is a non-invasive and reliable tool for diagnosis.

Isolation, Characterization, and Phylogenetic Analysis of Two New Crimean-Congo Hemorrhagic Fever Virus Strains from the Northern Region of Xinjiang Province, China

Crimean-Congo hemorrhagic fever (CCHF) caused by the CCHF virus (CCHFV) is a tick-borne natural focal disease with a mortality rate of approximately 50%. CCHFV is widely prevalent in Africa, southern Asia, the Middle East, and southeast Europe. CCHF outbreaks have been reported previously in Xinjiang province, China, especially in its southern region. Epidemiological surveys conducted on ticks and animals have revealed the presence of CCHFV strains in ticks, rodents, and infected individuals from cities and counties in southern Xinjiang. Phylogenetic analyses revealed that the Chinese CCHFV strains belong to one genotype, based on complete sequences of the S segments of its negative-stranded RNA genome. The present study reports two new CCHFV strains isolated from Hyalomma asiaticum asiaticum ticks collected from Fukang City and Wujiaqu City in the northern region of Xinjiang. Viral characteristics and their evolutionary relationships were analyzed through metagenomic and reverse-transcription PCR analyses; these analyses indicated that the genotype of both strains was different from that of other Chinese strains. Furthermore, previous reports of CCHFV in Xinjiang were reviewed and phylogenetic analyses were performed. CCHFV was found to prevail in Fukang City in Junggar Basin for more than 20 years, and that Fukang City and Wujiaqu City are considered natural reservoirs of different genotypes of CCHFV strains. Our findings facilitate the understanding of CCHFV distribution in Xinjiang province and provide insights into the evolutionary relationships among Chinese CCHFV strains.