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IJID One Health 7 (2025) 100067
Contents lists available at ScienceDirect
IJID One Health
journal homepage: www.sciencedirect.com/journal/ijid-one-health
The silent threat of Crimean-Congo hemorrhagic fever: an epidemiologic
analysis from five key high-risk regions of Afghanistan (2018–2024)
Enayatullah Hamdard
a,b,⁎
, Ahmadullah Zahir
c
, Naqibullah Mujadidi
c
, Nooruddin Himmat
d
a
College of Animal Science and Technology, Nanjing Agricultural University, Nanjing, China
b
Faculty of Veterinary Science and Medicine, Kunduz University, Kunduz, Afghanistan
c
Afghanistan National Agricultural Sciences and Technology University, Faculty of Veterinary Sciences, Kandahar, Afghanistan
d
World Health Organization, Regional Office, Kunduz, Afghanistan
ARTICLE INFO
Keywords:
Crimean-Congo hemorrhagic fever (CCHF)
Epidemiology
Regions
Awareness
Afghanistan
ABSTRACT
Objective: Afghanistan’s struggle with Crimean-Congo hemorrhagic fever (CCHF) is intensified by limited di-
agnostic and preventive resources. This study analyzed national surveillance data from five regions
(2018–2024), focusing on the Eid-al-Adha months (2022–2024), and examined demographics, occupations,
public awareness, and 2024 summer trends.
Methods: This study presents findings from a retrospective analysis of regional CCHF surveillance data from
2018 to 2024, analyzed using SPSS 23 and Power BI.
Results: From 2018 to December 2024, Afghanistan recorded 4445 suspected and 944 confirmed CCHF cases,
with a case fatality rate of 20.6% (i.e. 195 deaths). Annual confirmed cases were 139 in 2018, 167 in 2019, 178
in 2020, 189 in 2021, 15 in 2022, 114 in 2023, and 142 in 2024. Reverse transcription–polymerase chain
reaction and immunoglobulin M antibody tests identified 20.45% of confirmed cases, with the highest death toll
in 2018. From 2022–2024, 712 cases occurred during the Eid-al-Adha months, causing 61 deaths, peaking in
2023 with 313 cases and 30 deaths. In 2024, June had the most cases (204, case fatality rate 13%) and October
had the least (47 cases, case fatality rate 8.5%). Of the confirmed cases, 66% were male and 34% were female.
Occupations with the highest exposure included housewives (13.5%), shepherds (11.9%), butchers (8.7%),
health staff (4.6%), students (3.4%), and animal dealers/farmers (7.3%). In addition, 21.16% were unemployed,
and occupational data were missing for 29.3%.
Conclusions: The increase in CCHF outbreaks in Afghanistan from 2018 to 2024 highlights the challenges in
disease awareness and testing capacity. Early intervention is crucial for containing outbreaks in affected regions.
Introduction
Crimean-Congo hemorrhagic fever (CCHF) is a viral tick-borne dis-
ease in Afghanistan, with a 10-50% fatality rate. Its incidence is in-
creasing, with animals being the primary source of infection. Caused by
a negative-sense RNA virus from the Bunyaviridae family, CCHF is
transmitted mainly through ticks, especially Hyalomma species [1].
Wild animals (e.g. rabbits and hedgehogs) and domestic animals (e.g.
cattle, sheep, goats, and camels) serve as reservoirs, with cattle playing
a key role in virus spread [2,3]. Mild CCHF virus infections can be
asymptomatic, whereas severe cases may be life-threatening [4]. In
Afghanistan, the common symptoms include fever (85%), headache
(80%), joint pain (59%), nausea (47%), and myalgia (75%). Severe
cases show bruising, bleeding, and epistaxis with thrombocytopenia
[5]. CCHF is primarily transmitted through tick bites; however, human-
to-human transmission and contact with infected animal secretions are
also possible [5].
Eid al-Adha, also known as the “Festival of Sacrifice,” is a significant
Islamic holiday celebrated by Muslims worldwide. It commemorates
Prophet Ibrahim’s (Abraham’s) willingness to sacrifice his son as an act
of obedience to God. The festival involves the ritual slaughtering of
animals (such as sheep, goats, cows, or camels), and the meat is dis-
tributed among family, friends, and the needy in the community.
From the perspective of CCHF transmission, Eid al-Adha poses
specific public health risks in Muslim countries, particularly, in regions
where CCHF is endemic. CCHF is a tick-borne viral disease that can be
https://doi.org/10.1016/j.ijidoh.2025.100067
Received 17 February 2025; Received in revised form 22 March 2025; Accepted 31 March 2025
Available online 10 April 2025
2949-9151/© 2025 Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
]]]]
]]]]]]
⁎
Corresponding author at: College of Animal Science and Technology, Nanjing Agricultural University, Nanjing, China.
E-mail address: ehamdard1@gmail.com (E. Hamdard).
transmitted to humans through contact with infected animal blood or
tissues, particularly, during slaughtering or butchering.
CCHF is common in Afghanistan, particularly, in Kabul and Herat,
where livestock movement is poorly controlled [6]. Outbreaks often
spike during Eid al-Adha (June to September) due to unprofessional
slaughtering practices [7,8].
During Eid al-Adha (July 12-20, 2024), approximately 1 million
animals were slaughtered in Afghanistan, often purchased in advance
and kept in residential areas [9]. Due to a shortage of professional
butchers and religious practices, many people self-slaughter, increasing
the risk of animal-to-human CCHF transmission and contributing to
outbreaks [10]. Despite the spread of CCHF, data on its distribution,
prevention, and control remain limited [7], with knowledge gaps in
pathogenesis, transmission, treatment, and organ dysfunction markers
[6].
In Afghanistan, CCHF primarily affects livestock workers but also
impacts health care personnel, veterinarians, butchers, meat inspectors,
hunters, and the general population [2]. Occupational exposure to in-
fected animals and humans increases this risk [10]. CCHF is a priority
zoonotic disease, along with rabies and anthrax. Within the Hyalomma
tick's range, Afghanistan reports annual cases. Since the first case in
1998, CCHF cases have risen significantly, from 30 in 2018 to 947 in
2023, resulting in 100 deaths. The disease remains endemic in the
country.
In 2022, Afghanistan reported one of the highest numbers of CCHF
cases, with confirmed cases continuing to rise. However, laboratory
testing and case management remain limited [5]. Diagnostic methods
include enzyme-linked immunosorbent assay, antigen detection, virus
isolation, and reverse transcription–polymerase chain reaction (RT-
PCR), with RT-PCR being preferred for its simplicity and sensitivity
[6,11]. Early detection is crucial because of the high fatality rate and
lack of specific treatments or vaccines. CCHF remains a major public
health concern in regions with Hyalomma ticks, especially among those
involved in animal husbandry and slaughtering [6]. Transmission oc-
curs through tick bites, animal blood or secretions, and contaminated
instruments [12]. The preliminary steps to prevent CCHF in Afghani-
stan include the national strategy for zoonotic disease prevention and
control (2017-2021). A national task force for zoonosis has been es-
tablished to lead outbreak investigations and responses. Memoranda of
Understanding between key stakeholders, including the Ministry of
Public Health (MoPH), World Health Organization (WHO), Ministry of
Agriculture, and municipalities have been signed to improve colla-
boration for timely outbreak detection, investigation, and response
[10].
Despite progress, further improvements are needed in CCHF pre-
vention and control in Afghanistan, as highlighted by a 2018 WHO-
supported assessment. Key deficits include a lack of specific strategies,
limited resources, inadequate isolation facilities, insufficient stock of
antivirals (ribavirin), and low awareness among health care workers
and at-risk communities. In response, the MoPH, WHO, Ministry of
Agriculture, and other stakeholders developed a national CCHF pre-
vention and control plan [13]. The 2016 Joint External Evaluation also
recommended enhanced multisectoral cooperation, surveillance, and
information sharing for zoonotic diseases [9].
Recent studies have shown a rise in CCHF incidence in Afghanistan,
with limited resources for containment. The disease mainly affects
those aged 27-35 years, with a case fatality rate (CFR) between 11.5%
and 43.3%. Outbreaks have increased since 2013, with 1236 cases and
114 deaths reported in 2023, primarily, in the central and northern
regions [14,15]. Due to the absence of an approved vaccine or specific
treatment, further studies are needed for early detection and better
prevention. This study aimed to document the epidemiology of CCHF in
Afghanistan from 2018 to 2024 by analyzing data from the National
Disease Surveillance and Response and examining trends around Eid al-
Adha, including demographic, occupational, awareness, and knowledge
factors.
Materials and method
Study area
Afghanistan, a landlocked country approximately 300 miles
(480 km) from the Arabian Sea, is one of the least surveyed regions
worldwide because of its geographic isolation and complex political
history. It borders Pakistan, Iran, Turkmenistan, Uzbekistan, Tajikistan,
and China’s Xinjiang via the Wakhan Corridor. Approximately twice the
size of Norway, Afghanistan has a semiarid steppe climate with hot
summers and extremely cold winters, whereas the northeastern
mountains experience subarctic conditions. The country is divided into
34 provinces grouped into eight regions. This study focused on five
regions where CCHF cases surged from 2018 to 2024. Each region has
its own recording system within the National Disease Surveillance
System of the MoPH. Regional climates vary, with spring and summer
temperatures ranging from 15°C to 45°C (or 25–45°C in the east, west,
and south) [16].
Study design
This study presents a retrospective analysis of data from
Afghanistan’s National Disease Surveillance and Response system,
covering January to October 2018-2024. This study aimed to describe
the epidemiology of human CCHF cases across five regions, analyzing
seasonality, occupation, and demographic factors. This study also
compares CCHF outbreaks during Eid al-Adha (2022–2024) and as-
sesses regional knowledge and awareness of CCHF using a structured
questionnaire.
Study participants
This study included all suspected and confirmed cases reported to
the National Disease Surveillance and Response from January to
October each year from 2018 to 2024, totaling 5293 cases. The data
obtained from the WHO’s weekly infectious disease outbreak reports
were analyzed as secondary data [15].
Questionnaire for data collection
The questionnaire was developed by reviewing the WHO information
on CCHF epidemiology, transmission, precautions, seasonal impact, and
high-risk occupations [15,17]. It underwent two validation steps: first,
researchers and medical professionals assessed its clarity and relevance,
followed by the revisions. A pilot test with 100 participants from five re-
gions provided further feedback, resulting in the revision of two questions.
The final questionnaire included 12 questions, with “yes,” “no,” or “I don’t
know” responses for CCHF-related items.
In addition, community engagement activities identified further risk
factors for CCHF. The questionnaire, which featured closed, multiple-
choice, and open-ended questions on CCHF awareness, was adminis-
tered through moderated interviews in the local language with farm
owners after obtaining consent.
Data collection and report to NDSR
The MoPH, in collaboration with international agencies such as the
WHO, established regional infectious disease hospitals across
Afghanistan. Patients with suspected CCHF were admitted for ex-
amination and specimen collection. Provincial rapid response teams
conduct initial responses, collect specimens, complete CCHF case line
lists, and report to the national surveillance unit for laboratory testing
at the Central Public Health Laboratory. Specimens are tested via en-
zyme-linked immunosorbent assay for immunoglobulin M antibodies or
real-time RT-PCR, and the results are integrated into the national sur-
veillance database.
E. Hamdard, A. Zahir, N. Mujadidi et al. IJID One Health 7 (2025) 100067
2
We analyzed WHO outbreak reports from 2018 to 2024, focusing on
regional CCHF outbreaks and their correlation with the timing of Eid al-
Adha each year. Data from the structured questionnaire were analyzed
using SPSS and Power BI, and the results were independently reviewed
by two researchers for accuracy and reliability.
Statistical data analysis
Data were analyzed using SPSS Statistics version 23.0. Proportions
were calculated for qualitative variables, and the mean with SD and
median with interquartile range were calculated for quantitative vari-
ables. The chi-square and Fisher’s exact tests were used to assess the
associations between factors (gender, occupation, and knowledge level)
and CCHF seropositivity. Minitab 18 was used for statistical analysis,
with significance set at P < 0.05 [18]. Descriptive statistics and final
analysis were conducted using SPSS version 20.
Results
Regional CCHF seroprevalence in Afghanistan (2018–2024)
From 2018 to 2024, Afghanistan’s national surveillance system re-
corded 4445 suspected CCHF cases, 944 confirmed cases, and 195
deaths due to CCHF. Suspected cases by year were 483 in 2018, 285 in
2019, 392 in 2020, 448 in 2021, 389 in 2022, 1236 in 2023, and 1161
as of October 2024, with the highest numbers in 2023 and 2024.
Confirmed cases peaked in 2021 (189), followed by 2020 (178), 2019
(167), and 2018 (139), with the lowest number in 2022 (15). The
highest fatality rate was observed in 2018 (59 deaths).
From 2018 to 2024, Afghanistan’s average CFR for confirmed CCHF
cases was 26.5%, with annual variations of 31.7% in 2018, 23.1% in
2019, 19.4% in 2020, 14.5% in 2021, 1.6% in 2022, 5.4% in 2023, and
4.3% in 2024 (as of October). Despite the rising number of CCHF cases
until 2021, deaths declined, likely due to improved public knowledge,
timely responses, better blood supply, immunization, and preventive
measures (Figure 1).
Between 2022 and 2024, the number of CCHF cases varied across
regions. In 2022, the western and central regions had the highest
number of cases (129 and 117, respectively), with a low CFR of 0.77%
(three deaths). In 2023, the central, western, and eastern regions re-
ported 397, 353, and 239 cases, respectively, with a CFR of 0.80% (10
deaths). In 2024, the west led with 397 cases, followed by the central
(356) and east (234) regions, totaling 1161 cases and a CFR of 0.68%
(eight deaths) (Figure 1).
CCHF prevalence during Eid-al-Adha months by region (2022-2024)
Data from Afghanistan’s national surveillance system across five
regions (Central, West, East, North, and Northeast) showed the highest
CCHF prevalence in 2023, with 30 confirmed cases, representing 49.1%
of the year’s total cases (Figure 3). Between 2022 and 2024, Eid al-Adha
coincided with three CCHF case surges, resulting in 772 confirmed
cases and 61 deaths (Figure 2).
June 2023: the highest peak, with 313 cases and 30 deaths (CFR
49.1%), aligned with Eid-al-Adha on June 29.
June 2024: reported 285 cases and 25 deaths (CFR 40.9%).
July 2022: the lowest number of cases, with 114 cases and six deaths
(CFR 9.8%).
These patterns indicate a significant seasonal risk during Eid al-
Adha in all regions, highlighting the need for early intervention. To
prevent future outbreaks, enhanced biosecurity, tick control on animal
farms, and reduced human-animal contact are essential components of
a One Health approach (Figure 2).
Figure 1. Regional level CCHF reported cases to National Disease Surveillance System (2018–2024). It shows number of CCHF laboratory-confirmed and suspected
cases, with deaths in five regions of Afghanistan during the period of 2018–2024. The blue represents the number of suspected reported cases in five regions, green
color represents number of confirmed cases by laboratory, and dark blue indicates number of deaths through the years in relation to the region. The horizontal axis
indicates year frequency (from 2018 to 2024), and vertical axis shows the number of CCHF cases. CCHF, Crimean-Congo hemorrhagic fever.
E. Hamdard, A. Zahir, N. Mujadidi et al. IJID One Health 7 (2025) 100067
3
Comparison of CCHF reported cases in 2024 (January–October)
We analyzed CCHF outbreaks from January to October 2024 to iden-
tify the monthly trends. Cases were lowest in January, steadily increased
until July, and then declined through October (Figure 3). In May, 281
cases and 11 deaths were reported, resulting in a CFR of 3.91%. In June,
the number of cases increased to 301, with 29 deaths and a CFR of 9.6%.
In July, the number of cases decreased to 170, with 24 deaths and a CFR of
14.11%. From August to October, the number of cases and CFR decreased
significantly, with 120, 95, and 87 cases and 15, seven, and five deaths,
respectively (Figure 3). This pattern indicates that CCHF prevalence peaks
in hot weather, when tick transmission is most active (Figure 3).
Demographic and occupational characteristics of CCHF prevalence patterns
The analysis of demographic and occupational characteristics showed
that most CCHF cases were reported in the “others” category (29.3%),
followed by the unemployed (21.16%), housewives (13.53%), health staff
(4.6%), shepherds (11.96%), butchers (8.67%), animal dealers and
farmers (7.36%), and students (3.42%) (Table 1). Of the 4080 individuals
analyzed, 66% (2652) were male and 34% (1428) were female, reflecting
gender roles in Afghanistan, where men are more likely to engage in
outdoor labor and women focus on household duties (Table 1).
Regionally, the highest number of CCHF cases occurred in the west (1381),
followed by the central (1242), eastern (761), northern (362), and northeastern
(334) regions (Table 1). These patterns highlight regional vulnerability to
CCHF, emphasizing the need for further investigations into the disease epide-
miology across different occupational and demographic groups (Table 1).
Awareness assessment of local inhabitants regarding CCHF
A structured questionnaire with 12 questions about CCHF was ad-
ministered across five regions of Afghanistan to assess local knowledge
of the disease. A total of 1000 participants, with 100 from each region,
were surveyed, including 75% males (750) and 25% females (250)
(Table 2).
Regarding awareness of CCHF, 679 respondents answered “yes,”
indicating basic awareness, although many lacked detailed knowledge.
The remaining 247 answered “no,” and 74 responded with “I don’t
know.” When asked whether building awareness of CCHF could help
mitigate the disease, 375 participants agreed, 269 disagreed, and 356
were unsure. This suggests that many do not fully recognize the im-
portance of awareness in disease prevention, likely due to the high il-
literacy rates in the community (Table 2).
During the interviews, the participants were asked whether they
believed CCHF was transmitted through tick bites. Of the 1000 re-
spondents, 369 believed it was a disease, 283 disagreed, and 348 were
unaware. This lack of awareness likely contributes to the higher pre-
valence of CCHF in these regions (Table 2).
Regarding whether CCHF is a health threat to humans, 359 parti-
cipants recognized the danger, 419 rejected it, and 222 were unaware
of its public health impact, despite its high fatality rate (10-45%). When
asked if CCHF could be transmitted through direct contact with infected
animals, 218 respondents agreed, 569 disagreed, and 218 were unsure,
indicating some understanding of its zoonotic nature but also sig-
nificant knowledge gaps (Table 2).
Regarding the prevalence of CCHF in their region, 213 respondents
answered “yes,” 393 said “no,” and 394 were unsure, suggesting either
a lack of awareness of the disease or uncertainty about its presence in
the area (Table 2).
Regarding knowledge of therapies and vaccines for CCHF, 224
participants believed they were available, whereas 941 did not, re-
flecting a significant lack of awareness of preventive and treatment
options. Only 139 respondents correctly identified CCHF as a zoonotic
disease transmitted through tick bites and human-to-human contact.
When asked about transmission through social contact, air, or water,
Figure 2. Comparison of CCHF confirmed cases on Eid-al-Adha months (2022-2024). This figure shows reported confirmed cases during Eid-al-Adha months in the
national surveillance system on the national level during 2022-2024. The green color represents reported cases per week, the dark blue represents the number of
deaths per week, the yellow color represents respective month, and purple color represent reported cases during the entire month in which Eid-al-Adha happened and
purple also represents the cumulative number of deaths reported during the entire month. CCHF, Crimean-Congo hemorrhagic fever.
E. Hamdard, A. Zahir, N. Mujadidi et al. IJID One Health 7 (2025) 100067
4
the majority (1120) answered “no,” indicating confusion or a lack of
understanding of how CCHF spreads (Table 2).
Overall, the survey revealed low awareness of CCHF, with many
respondents misinformed or uncertain about the disease and its trans-
mission routes. With 4810 responses saying “no” and 4283 saying “I
don’t know,” compared with just 2907 affirmative answers, the data
underscore the need for improved public health education. This high-
lights the urgency of early mitigation efforts, including enhanced bio-
security and tick prevention measures, in Afghanistan.
Discussion
Afghanistan is experiencing a significant nationwide increase in the
incidence of CCHF. Domestic animals, such as cattle, sheep, goats, ca-
mels, and chickens, act as reservoirs and spread the virus via tick bites
or direct contact. Since 2018, Afghanistan has reported an annual in-
crease in CCHF cases and deaths, with surveillance data from five re-
gions recording 4445 suspected cases, 944 confirmed cases, and 195
deaths, respectively. The highest number of confirmed cases occurred in
2023 (1236), whereas deaths have declined since peaking in 2018 [10].
Our investigation analyzed the annual CCHF incidence across five re-
gions from 2018 to 2024. Cases increased steadily from 2018 to 2021,
declined in 2022, and then increased again in 2023 and 2024. The case
fatality ratio was highest in 2018 (31.1%) and decreased each year to 1.6%
in 2022 but increased again to 5.3% in 2023 and 4.3% in 2024 (through
October). These trends suggest an increasing overall incidence of CCHF
cases from 2018 to 2024 compared with that in the previous years [15].
Our findings on the occupational transmission of CCHF from 2018 to
2024 align with those of previous studies [19]. Most cases occurred
among individuals classified as “others” (29.3%), followed by the un-
employed (21.6%), housewives (13.5%), health staff (4.6%), shepherds
(11.9%), butchers (8.6%), animal dealers and farmers (7.3%), and
students (3.4%). These patterns are consistent with studies by Ahmad
et al., Dr. Sahak, and research in Pakistan, which reported CFR rates
between 10% and 40% [4,6].
Housewives may be at risk of CCHF due to exposure to animal blood
while cooking and a lack of safety protocols during meat preparation. In
the past 3 years, 14 (13%) cases have been reported among health care
staff in Afghanistan, although no nosocomial infections have been re-
corded. The WHO warns that human-to-human transmission can occur in
health care settings through contact with patient blood, secretions, or body
fluids [10,20]; student cases might stem from accidental exposure to ticks
or animals. A Turkish study identified agriculture, animal husbandry, and
health care workers as high-risk groups for HZ [21]. Similarly, previous
studies have highlighted slaughterhouse workers, butchers, and livestock
handlers as high-risk occupations for CCHF [22]. This study aligns with
previous research, showing similar occupational patterns of CCHF pre-
valence across the five regions in Afghanistan.
Program experts suggest that environmental factors may contribute
to the increase in CCHF cases. Drought and fodder shortages in the West
and North regions have dried pastures, prompting livestock and people
to migrate to areas with better grazing, increasing their exposure to
infected ticks as herds intermingle [4,6]. Improved surveillance may
also play a role; since 2015, over 250 health workers from the public
and animal health sectors have been trained to manage CCHF. Public
awareness has increased through media campaigns, brochures, and
outreach by the FAO and WHO, with 600 religious leaders educating
communities. However, no epidemiologic studies have confirmed the
cause of the increase in the number of cases [10].
From 2015 to 2024, Afghanistan has seen an annual increase in
confirmed CCHF cases, especially during Eid al-Adha, which occurs
between June and September. An analysis of data from 2022 to 2024
for the Eid-al-Adha months showed a total of 712 confirmed cases and
61 deaths. The highest figures were in 2023 (313 cases, 30 deaths) and
Figure 3. Comparison of CCHF reported cases in 2024 (January-October). This figure shows national comparison of CCHF reported cases to the national surveillance
system in the year 2024 from January to October monthly. The blue represents the central region, the dark blue represents west region, the yellow color represents
east region, the purple color represents north region, and the pink color represent Northeast region. Death, CFR, and total for each month are shown. The horizontal
axis indicates month frequency (from January to October 2024), and the vertical axis shows the number of CCHF reported cases. CCHF, Crimean-Congo hemorrhagic
fever; CFR, case fatality rate.
E. Hamdard, A. Zahir, N. Mujadidi et al. IJID One Health 7 (2025) 100067
5
Table 1
Demographic and occupational characteristics of CCHF cases (occupational patterns).
Occupational
Infection of
CCHF
Year 2018-2024
Central region East region West region North region Northeast region Grant total Grant
percentage
CCHF
cases
(n)
Positive CCHF
cases (%)
CCHF cases
(n)
Positive CCHF
cases (%)
CCHF cases
(n)
Positive CCHF
cases (%)
CCHF cases
(n)
Positive CCHF
cases (%)
CCHF cases
(n)
Positive CCHF
cases (%)
Animal dealer 71 5.716586151 27 3.547963206 57 4.127443881 22 6.077348066 24 7.185628743 201 26.65497005
Butcher 87 7.004830918 66 8.672798949 63 4.561911658 31 8.563535912 35 10.47904192 282 39.28211935
Farmer 62 4.99194847 29 3.810775296 71 5.141202028 36 9.944751381 28 8.383233533 226 32.27191071
Health staff 89 7.165861514 35 4.599211564 83 6.010137581 13 3.591160221 21 6.28742515 241 27.65379603
Housewife 146 11.75523349 103 13.5348226 134 9.703113686 29 8.011049724 31 9.281437126 443 52.28565663
Shepherd 121 9.742351047 91 11.95795007 127 9.196234613 30 8.287292818 22 6.586826347 391 45.77065489
Student 37 2.979066023 26 3.416557162 42 3.041274439 21 5.801104972 19 5.688622754 145 20.92662535
Unemployed 289 23.2689211 161 21.15637319 335 24.25778421 77 21.27071823 67 20.05988024 929 110.013677
Others 340 27.37520129 223 29.30354796 469 33.9608979 103 28.45303867 87 26.04790419 1222 145.14059
Total 1242 100 761 100 1381 100 362 100 334 100 4080 500
Male 2652 66%
Female 1428 34%
0
50
100
150
200
250
300
350
400
450
500
Central Region East Region West Region North Region Northeast Region
Chart Title
Animal delar Butcher Farmer Health staff Housewife Shepherd Student Unemployed Others
This table represents the demographic and occupational characteristics of CCHF cases within five study regions of Afghanistan.
CCHF, Crimean-Congo hemorrhagic fever.
E. Hamdard, A. Zahir, N. Mujadidi et al. IJID One Health 7 (2025) 100067
6
2024 (285 cases, 25 deaths), followed by 2022 (114 cases, 6 deaths)
(Fig. 3). In 2024, Eid-al-Adha, which occurred on June 17, likely con-
tributed to increased CCHF cases due to limited awareness, unsafe an-
imal slaughter practices, and cross-border animal movement [2].
Previously, Eid-al-Adha fell in autumn or winter; however, in the
next 10-15 years, it will increasingly coincide with summer months,
when animals are more likely to be viremic due to ticks. This shift could
intensify CCHF virus infections because summer months heighten in-
fection risks due to unsafe slaughtering, insufficient disease awareness,
and unrestricted animal movements [2].
Our analysis suggests a potential rise in CCHF cases in the coming
years if strict mitigation measures are not enforced, which is consistent
with previous studies [5,8,10,15,23]. One report noted that 2018 had
the highest number of recorded cases in Afghanistan, with 483 cases,
and an outbreak from week 19 to week 37. Seasonal trends indicate that
CCHF cases increase in May and decline in October [10].
In 2024, from January to October, data from five regions showed an
increase from 17 to 90 cases between January and April, peaking in
May, June, and July (281, 301, and 170 cases, respectively) before
declining from August to October (120, 95, and 87 cases).
There is limited research on CCHF knowledge, awareness, and One
Health practices in endemic areas such as Afghanistan. To the best of our
knowledge, this study is the first to assess public familiarity with CCHF
across five endemic regions where transmission is common [24,25].
The study found that 679 participants were familiar with CCHF, 247
declined to confirm their familiarity, and 74 were unaware of it. When
asked about the importance of awareness for CCHF mitigation, 375
agreed, 269 disagreed, and 356 were uncertain, indicating that a sub-
stantial portion of the population lacks understanding of awareness in
disease prevention, likely due to high community illiteracy.
Only 11.6% of participants knew that CCHF is a zoonotic disease
transmitted by tick bites and direct contact with infected animals or
people, whereas 81.4% across all five regions were unaware.
Comparative studies in Pakistan, Afghanistan, and Iran have shown
CCHF awareness levels ranging from 42% to 67.4% regarding trans-
mission, infection modes, and peak months [14,17,26].
Overall, low awareness levels were evident, with many respondents
unsure or misinformed about the transmission of CCHF. With 4810
responses as “no” and 4283 as “I don’t know” compared with just 2907
affirmative answers, the findings highlight the urgent need for stronger
public health education. Enhanced biosecurity and tick prevention are
essential for improving public health in Afghanistan.
Research has confirmed that people can intentionally forget in-
formation, making reminders essential for retaining knowledge
[27,28]. Access to reliable sources, such as the WHO and Centers for
Disease Control and Prevention, is vital for accurate information, en-
couraging governments and One Health policymakers to promote these
resources.
Afghanistan’s MoPH and Ministry of Agriculture should hold regular na-
tional conferences, workshops, and seminars to build staff capacity and raise
awareness of public health threats, particularly, before peak disease seasons
[14,17]. Further research is crucial to identify the factors driving CCHF
spikes, especially around Eid al-Adha, and develop public health strategies
that effectively curb the spread of infectious diseases within the country.
Conclusion
Afghanistan, located within the Hyalomma tick’s ecological range, ex-
periences a yearly increase in CCHF cases. The variation in seropositivity in
our study is linked to CCHF’s endemic nature of CCHF, the abundance of
ticks, and host behavior influenced by climate change and drought.
The growing prevalence of CCHF poses a serious public health threat,
especially with recent increases in cases and mortality. Our findings under-
score the need for urgent control measures from a One Health perspective.
Despite the increase in cases, Afghanistan’s laboratory capacity for
testing and knowledge of CCHF management remains limited. Early
detection and identification of animal host risk factors are crucial for
mapping the endemic areas. Given CCHF’s impact of CCHF on human
health, particularly, among those in contact with animals, raising
awareness, improving livestock practices, and enhancing disease sur-
veillance are key to controlling its spread.
Table 2
Awareness level of demographics within the study regions.
Questions Yes Percentage (%) No Percentage (%) I don’t know Percentage (%)
Do you know CCHF? 679 56.58333333 247 20.58333333 74 6.166666667
Is CCHF transfer through tick bites? 369 30.75 283 23.58333333 348 29
CCHF is zoonotic disease 139 11.58333333 173 14.41666667 688 57.33333333
CCHF is a human health threatening disease 359 29.91666667 419 34.91666667 222 18.5
CCHF can be transfer through direct contact with infected animals 213 17.75 569 47.41666667 218 18.16666667
CCHF can be transfer through air and water 89 7.416666667 641 53.41666667 270 22.5
CCHF can be transfer through social contact 93 7.75 479 39.91666667 428 35.66666667
CCHF can be transfer from infected humans to healthy humans 154 12.83333333 429 35.75 417 34.75
CCHF is common in your region? 213 17.75 393 32.75 394 32.83333333
Is CCHF have therapy? 157 13.08333333 396 33 447 37.25
Is CCHF have vaccine? 67 5.583333333 512 42.66666667 421 35.08333333
Is building awareness regarding CCHF is useful for mitigating
CCHF?
375 31.25 269 22.41666667 356 29.66666667
2907 242.25 4810 400.8333333 4283 356.9166667
It shows regional level of awareness of inhabitants toward CCHF and explicitly illustrate the interviewed inhabitants’ responses against specific questions. From left to
right, the first column has 12 questions and the answers are recorded under each region column. For every question on a regional level, there are three answers (yes,
no, or I don’t know). The answers are analyzed numerically and using percentage.
CCHF, Crimean-Congo hemorrhagic fever
E. Hamdard, A. Zahir, N. Mujadidi et al. IJID One Health 7 (2025) 100067
7
Author contributions
Enayatullah Hamdard: Investigation, Methodology,
Conceptualization, writing – original draft, Writing – review &
editing. Ahmadullah Zahir: Formal analysis, Data curation, Writing –
review & editing. Naqibullah Mujadidi: Formal analysis, Data cura-
tion, Writing – review & editing. Nooruddin Himmat: Investigation,
Writing – review & editing.
Ethical approval
This study is based on a secondary data analysis of available sur-
veillance data, and human subjects were not directly involved in the
data collection. Therefore, ethical approval was not required. The in-
habitants participated in face-to-face assessments to assess their
awareness of CCHF, and consent was obtained before the interview.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors have no competing interests to declare.
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