Colorized scanning electron micrograph of viral CCHF particles in yellow CCHF occurs most frequently among agricultural workers, following the bite of an infected tick, and to a lesser extent among slaughterhouse workers exposed to the blood and tissues of infected livestock, and medical personnel through contact with the body fluids of infected persons. Geographic distribution the northern limit of CCHF has been 50 degrees northern latitude, north of which the Hyalomma ticks have not been found. Per a WHO map from 2008, Hyalomma ticks occurred south of this latitude across all of the Eurasian continent and Africa, sparing only the islands of Sri Lanka, Indonesia and Japan. Serological or virological evidence of CCHF was widespread in Asia, Eastern Europe, the Middle East (except Israel, Lebanon and Jordan), central Africa, Western Africa, South Africa and Madagascar. In 2008, more than 50 cases/year were reported from only 4 countries: Turkey, Iran, Russia and Uzbekistan. 5-49 cases/year were present in South Africa, Central Asia including Pakistan and Afghanistan (but sparing Turkmenistan), in the Middle East only the UAE and the Balkan countries limited to Romania, Bulgaria, Serbia, Montenegro and Kosovo-Albania. In Russia, the disease is limited to Southern and North Caucasian Federal Districts, but climate change may cause it to spread into more northerly areas. A 2014 map by the CDC shows endemic areas (in red) largely unchanged in Africa and the Middle East, but different for the Balkan, including all countries of the former Yugoslavia, and also Greece, but no longer Romania. India's Northwestern regions of Rajastan and Gujarat saw their first cases. Outbreaks From 1995 to 2013, 228 cases of CCHF were reported in the Republic of Kosovo, with a case-fatality rate of 25.5%. Between 2002–2008 the Ministry of Health of Turkey reported 3,128 CCHF cases, with a 5% death rate. In July 2005, authorities reported 41 cases of CCHF in central Turkey's Yozgat Province, with one death. As of August 2008, a total of 50 deaths were reported for the year thus far in various cities in Turkey due to CCHF. In September 2010, an outbreak was reported in Pakistan's Khyber Pakhtunkhwa province. Poor diagnosis and record keeping caused the extent of the outbreak to be uncertain, though some reports indicated over 100 cases, with a case-fatality rate above 10%. In January 2011, the first human cases of CCHF in India was reported in Sanand, Gujarat, India, with 4 reported deaths, which included the index patient, treating physician and nurse. , 71 people were reported to have contracted the disease in Iran, resulting in 8 fatalities. In October 2012, a British man died from the disease at the Royal Free Hospital in London. He had earlier been admitted to Gartnavel General Hospital in Glasgow, after returning on a flight from Kabul in Afghanistan. In July 2013, seven persons died due to CCHF in Kariyana village in Babra taluka, Amreli district, Gujarat, India. In August 2013, a farmer from Agago, Uganda was treated at Kalongo Hospital for a confirmed CCHF infection. The deaths of three other individuals in the northern region were suspected to have been caused by the virus. Another unrelated CCHF patient was admitted to Mulago Hospital on the same day. The Ministry of Health announced on the 19th that the outbreak was under control, but the second patient, a 27-year-old woman from Nansana, died on the 21st. She is believed to have contracted the virus from her husband, who returned to Kampala after being treated for CCHF in Juba, South Sudan. In June 2014, cases were diagnosed in Kazakhstan. Ten people, including an ambulance crew, were admitted on to hospital in southern Kazakhstan with suspected CCHF. In July 2014 an 8th person was found to be infected with CCHF at Hayatabad Medical Complex (HMC), Pakistan. The eight patients, including a nurse and 6 Afghan nationals, died between April and July 2014. , sporadic confirmed cases have been reported from Bhuj, Amreli, Sanand, ar and Vadnagar in Gujarat, India. In November 2014, a doctor and a labourer in north Gujarat tested positive for the disease. In the following weeks, three more people died from CCHF. In March 2015, one more person died of CCHF in Gujarat. As of 2015, among livestock, CCHF was recognized as "widespread" in India, only 4 years after the first human case had been diagnosed. In August 2016, the first local case of CCHF in Western Europe occurred in Western Spain. A 62-year-old man, who had been bitten by a tick in Spain died on August 25, having infected a nurse. The tick bite occurred in the province of Ávila, 300 km away from the province of Cáceres, where CCHF viral RNA from ticks was amplified in 2010. it was unclear what specific ecology led to the Spanish cases. In August 2016, a number of Pakistani news sources raised concerns regarding the disease. Between January and October 2016, CCHF outbreaks in Pakistan were reported with highest numbers of cases and deaths during August 2016, just before the festival of Eid-al-Adha (held on September 13–15 in 2016). It was hypothesized that the festival could play an important part as people could come into contact with domestic or imported animals potentially infected with CCHF virus. The Pakistani NIH showed there was no correlation, and that CCHF cases have coincided with the peak tick proliferation during the preceding 8–10 years. In 2017, the General Directorate of Public Health in Turkey, published official records of infections and casualties of<unk>  seen between 2008-2017. Hundreds of cases were observed each year with the lowest being 343 in 2017, and the highest being 1318 in 2009 whereas the mortality rate per population decreasing consistently each year. Geographically cases are concentrated in the Central Black Sea Region, mostly in Yozgat Province and surrounding provinces, mountainous parts of Central Anatolia, and northern provinces of Eastern Anatolia. On February 5, 2020, an outbreak occurred in the central region of Mali. The infected are from Douentza and Mopti region. So far 7 people have died.
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