Why Crimean-Congo Hemorrhagic Fever (CCHF) Persists Annually in Iraq: A Comprehensive Analysis

 

 

 

Dr. Majed Hamed Al Saegh / poultry pathologist / Australia

 

1. Introduction

Crimean-Congo Hemorrhagic Fever (CCHF) is one of the most severe and persistent zoonotic diseases affecting Iraq, classified as a biosafety level 4 pathogen due to its high mortality rate and pandemic potential. Iraq reported its first confirmed case in 1979, and since then, the disease has become endemic, with annual outbreaks increasing in scale and severity, culminating in the record-breaking 2023 outbreak with 587 confirmed cases and 83 deaths.

 

The persistence of CCHF in Iraq is not coincidental. It is the result of a complex interplay of ecological, cultural, political, and public health failures. This report presents a detailed analysis of the underlying causes and contributing factors to this recurring health crisis.

 

2. Key Drivers Behind the Annual Recurrence of CCHF in Iraq

2.1. Ecological and Environmental Factors

2.1.1. Climate and Geography

• Iraq’s semi-arid to arid climate provides ideal conditions for Hyalomma ticks, the primary vector of CCHFV.
• Seasonal fluctuations, especially in spring and early summer, create optimal tick breeding and feeding conditions.
• Poor rainfall and increased desertification force animal movement toward populated areas, increasing human-vector contact.

 

2.1.2. Tick Population Expansion

• Lack of coordinated tick control programs.
• Discontinuation of livestock spraying and dipping campaigns, particularly during and after the COVID-19 pandemic, allowed vector populations to proliferate.

 

2.2. Agricultural and Livestock Practices

2.2.1. Traditional Farming and Backyard Slaughter

• Many Iraqis raise livestock at home, often in close contact with humans.
• Home slaughtering, especially during religious holidays (e.g., Eid al-Adha, Ashura), significantly increases exposure to blood and tissues from infected animals.

 

2.2.2. Unregulated Animal Trade

• Cross-border smuggling of livestock, especially from endemic regions in neighbouring countries like Iran and Turkey, introduces new CCHFV strains.
• Lack of veterinary quarantine or inspection enables infected animals to spread the virus.

 

2.2.3. Illegal and Freelance Slaughterers :An estimated 7,000 unlicensed slaughterhouses operate without health oversight. With Lack of sanitation, PPE, and awareness among butchers increases zoonotic transmission risk.

 

2.3. Socio-Cultural Risk Factors

2.3.1. Religious and Cultural Events

• Eid al-Adha and Muharram attract mass gatherings and ritual slaughter, leading to:
• Increased animal-human interaction.
• Improper waste disposal (blood, skin, organs).
• Expansion of the disease from rural to urban areas through the movement of livestock.

 

2.3.2. Gender Roles and Household Risks

• A significant number of housewives are exposed to fresh raw meat while preparing meals without protection.
• Children and rural families often help with livestock care and slaughter, increasing household exposure.

 

2.4. Public Health Infrastructure and Surveillance Weaknesses

2.4.1. Underfunded Surveillance Systems

• Most rural areas lack real-time surveillance or early detection tools.
• Outbreaks are often reported after escalation, delaying response.

 

2.4.2. Limited Diagnostic Capacity:  Only one or few central labs (e.g., Baghdad Central Public Health Laboratory) have capacity for RT-PCR confirmation under high biosafety conditions. Delay in testing and results reduces containment effectiveness.

 

2.4.3. Incomplete Data Collection: Many case investigation forms lack proper documentation on exposure history, risk factors, or occupations. This hampers accurate epidemiological analysis and targeted interventions.

 

2.5. Weak Vector and Animal Health Management

2.5.1. Disrupted Vector Control Post-COVID

• During 2020–2021, Iraq’s veterinary services were suspended due to COVID-19.
• Spraying and dipping campaigns were halted, resulting in a significant resurgence of Hyalomma ticks.

 

2.5.2. No Regular Tick Surveillance in Livestock :No national program for tick infestation monitoring or CCHFV seroprevalence testing in animals.

 

2.5.3. Failure to Implement ‘One Health’ Approach

• Weak coordination between human health, veterinary, and environmental authorities.
• Lack of interdisciplinary collaboration limits prevention.

 

2.6. Political Instability and Governance Challenges

2.6.1. Decades of Conflict and Weak Governance

• Iraq’s healthcare and veterinary infrastructure has been fragmented by wars, sanctions, and corruption.
• Decentralised, under-resourced provincial health systems cannot cope with large outbreaks.

 

2.6.2. Corruption in Public Health and Agriculture Sectors

• Funding allocated to animal health and vector control is often mismanaged or insufficient.
• Freelance, unlicensed veterinarians and slaughterhouses operate with impunity due to lack of enforcement.

 

2.7. Public Awareness and Risk Communication Deficits

• There is minimal public education about tick-borne diseases, safe meat handling, or tick bite prevention.
• No national awareness campaigns during peak seasons (spring–summer).
• Most people in high-risk groups (butchers, farmers, housewives) lack access to information or PPE.

 

3. Highlights from the 2023 Outbreak

• 587 confirmed cases and 83 deaths (CFR 14%)—the highest on record.
• Southern provinces (Dhi-Qar, Maysan, Basrah) contributed nearly 71% of confirmed cases.
• Religious occasions in June–July (Eid al-Adha and Moharram) amplified transmission.
• High proportion of patients had exposure to fresh raw meat (60%) and animal slaughter (48%).
• Only 8% had a recorded tick bite, highlighting the difficulty in recognising tick exposure.

 

4. Recommendations

4.1. Strengthen Vector and Animal Health Management

• Resume and fund tick control campaigns across provinces.
• Initiate national livestock tick infestation monitoring.
• Develop animal movement tracking to prevent cross-border introduction of infected livestock.

 

4.2. Enhance Public Health Surveillance

• Train and equip local health directorates in rapid CCHF detection and biosafety.
• Establish mobile diagnostic labs to decentralise PCR testing.
• Improve data completeness in all surveillance forms.

 

4.3. Public Awareness and Behavioural Change

• Launch nationwide campaigns in Arabic and Kurdish targeting butchers, farmers, and housewives.
• Distribute low-cost PPE kits before religious slaughter events.
• Promote safe meat handling and discourage home slaughter.

 

4.4. Legislation and Policy Enforcement

• Enforce regulations against illegal slaughterhouses.
• Penalise unlicensed livestock trading and butchery.
• Encourage the development of mobile veterinary slaughter units for rural areas.

 

4.5. Adopt a One Health Framework

• Integrate veterinary, environmental, and public health sectors for early warning.
• Collaborate with international agencies (FAO, WHO, OIE) to develop a regional CCHF strategy.
• Train community health workers and veterinarians together on CCHF prevention.

 

5. Conclusion

Crimean-Congo Hemorrhagic Fever has evolved from a sporadic zoonosis to an annual health crisis in Iraq, driven by structural weaknesses in public health, veterinary services, environmental management, and public education. The 2023 outbreak is not an isolated event but a consequence of systemic neglect and ecological changes worsened by the COVID-19 pandemic. If Iraq is to prevent further escalation and regional spillover, it must adopt a sustainable, multisectoral approach rooted in One Health, backed by robust legislation, tick control, and community awareness. Without decisive action, CCHF will continue to burden Iraq’s healthcare