title: Crimean-Congo haemorrhagic fever in travellers: A systematic review.
abstract: BACKGROUND
  The recent Ebola epidemic has increased public awareness of the risk of travel associated viral haemorrhagic fever (VHF). International preparedness to manage imported cases Ebola virus infection was inadequate, highlighted by cases of nosocomial transmission. Crimean-Congo haemorrhagic fever (CCHF) is a re-emerging tick-borne VHF centred in the Eurasian region, affecting a large geographical area and with human-to-human transmission reported, especially in the healthcare setting.
  
  
  OBJECTIVE
  To systematically review the characteristics of travel associated Crimean-Congo haemorrhagic fever.
  
  
  METHODS
  A systematic review of travel-associated cases of CCHF was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement protocol. PubMed, SCOPUS, Science Citation Index (SCI) and ProMED databases were searched for reports published between January 1960 and January 2016. Three independent reviewers selected and reviewed studies and extracted data.
  
  
  RESULTS
  21 cases of travel associated CCHF were identified, of which 12 died (3 outcome unknown) and 4 secondary (nosocomial) infections were reported. Risk occupations or activities for CCHF infection were reported in 8/12 cases when data were available. Travel from Asia to Asia occurred in 9 cases, Africa to Africa occurred in 5 cases, Africa to Europe in 3 cases, Asia to Europe in 2 cases and Europe to Europe in 2 cases.
  
  
  CONCLUSIONS
  CCHF related to travel is rare, is generally associated with at risk activities/occupation and is frequently fatal. Key to early diagnosis and prevention of nosocomial transmission is an understanding of CCHF risk factors and the geographical distribution of CCHF. International travel to CCHF endemic areas is increasing and clinicians and laboratory personnel managing returning travellers should maintain a high index of suspicion.
authors.affiliation: Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University Medical School, Samsun, Turkey. Electronic address: hakanomu@yahoo.com.
authors.forename: Hakan
authors.initials: H
authors.lastname: Leblebicioglu
authors.affiliation: Department of Infectious Diseases and Clinical Microbiology, Istanbul University Cerrahpasa Medical School, Istanbul, Turkey.
authors.forename: Resat
authors.initials: R
authors.lastname: Ozaras
authors.affiliation: Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University Medical School, Samsun, Turkey; Liverpool School of Tropical Medicine, Liverpool L3 5QA, United Kingdom.
authors.forename: Tom E
authors.initials: TE
authors.lastname: Fletcher
authors.affiliation: Liverpool School of Tropical Medicine, Liverpool L3 5QA, United Kingdom; NIHR HPRU in Emerging and Zoonotic Infections, University of Liverpool, Liverpool L69 7BE, United Kingdom.
authors.forename: Nick J
authors.initials: NJ
authors.lastname: Beeching
mesh_terms: D000349:Africa / Q000453:epidemiology; D000818:Animals; D001208:Asia / Q000453:epidemiology; D003428:Cross Infection / Q000453:epidemiology* / Q000401:mortality / Q000635:transmission; D005060:Europe / Q000453:epidemiology; D003225:Hemorrhagic Fever Virus, Crimean-Congo / Q000502:physiology; D006479:Hemorrhagic Fever, Crimean / Q000453:epidemiology* / Q000401:mortality / Q000635:transmission; D006801:Humans; D012307:Risk Factors; D017282:Tick-Borne Diseases / Q000453:epidemiology* / Q000401:mortality / Q000635:transmission; D014195:Travel
keywords: Crimean-Congo haemorrhagic fever; Imported; Migration; Travel; Viral haemorrhagic fevers