This viral haemorrhagic fever is considered endemic in the Balkans with Bulgaria reporting two to eight cases a year since 2013. The first autochthonous human outbreak of CCHF in south west Europe was in 2016, with two cases in Madrid, one of which was fatal. The mortality rate is around 30 per cent, with death usually occurring in the second week of infection.33,34

It is usually spread by ticks or through contact with animal blood and tissues, but human to human transmission by close contact with body fluids is possible. Symptoms include fever, pain and stiffness, photophobia, gastric upset, and sharp mood swings and confusion. Tachycardia and swollen lymph nodes are possible, with a rash appearing on the skin or on mucosa.35

Treatment is generally supportive, and ribavirin can be effective. No vaccine has been licensed for widescale use, although an inactivated, mouse brain-derived vaccine is used in eastern Europe on a small scale. Prevention is mainly in avoiding tick bites or transmission from contact.