the 9 hcws and all cchf patients under their care were admitted to the infectious diseases and clinical microbiology clinic ( idcm ) of ankara numune education and research hospital ( ankara , turkey ) during 20042011 with confirmed cchf . all 9 hcws were aware of possible or confirmed cchfv infection in their patients . during this period , 7,000 confirmed cchf cases were recorded in turkey ; nearly 300 of these patients were hospitalized in idcm . acute- and convalescent - phase serum samples from the index patients were sent to the national reference laboratory of turkey . cchfv infection was confirmed through igm positivity by elisa and/or positive pcr results for cchfv in blood . after episode 1 , the hcws serum samples were sent to the pasteur institute ( lyon , france ) for contact tracing . the hcws infections were scored according to a severity score index ( 12 ) . in episode 3 , to investigate the source of infection , molecular techniques were used . oral ribavirin for treatment was administered at the dosage recommended by the world health organization ( 4 g / d for 4 d , 2.4 g / d for 6 d ) , and for prophylaxis ( 2g/4/d for 7 d ) . the index patients and the hcws were given erythrocyte , fresh frozen plasma , and total blood preparations depending on their homeostasis . in 2005 , cchfv infection was diagnosed in a woman on the day of delivery by cesarean section . she was transferred to idcm , and her baby was transferred to the newborn service at the dr . a nurse in idcm , who had fever and myalgia , was later found to have cchfv infection ( table 1 ) . transmission was related to the improper use of gloves during the care of the mother s surgical wound . a nurse in the neonatal clinic in the children s hospital also acquired cchfv infection , which was attributed to the intubation and aspiration of bloody secretions from the baby without proper use of gloves and mask . the second nurse s illness was mild ; because she had a potential for getting pregnant , ribavirin was not started . * hcw , health care worker ; ast , aspartate aminotransferase ; alt , alanine aminotransferase ; aptt , activated partial thromboplastin time ; ssi , severity score index . reference values : leukocytes , 4,00011,000/mm ; platelets , 150,000450,000/mm ; ast , < 50 iu / l ; alt , < 50 iu / l ; aptt , 2436 sec ; fibrinogen , 200400 mg / dl . serum samples from 37 hcws at idcm and the obstetrics and newborn clinics at the children s hospital who were at risk for infection were investigated for cchf . in addition to the 2 nurses , 2 nurses from the neonatal clinic were cchf igm positive but were asymptomatic . in 2006 , a nurse received a needlestick injury during a phlebotomy of a cchfv - infected patient . she was using gloves but no gown , and the needle stuck to her forearm . the nurse s symptoms began 2 days after the incident , and she was transferred to idcm 4 days after the incident . at admission , she had ecchymosis , epistaxis , hematemesis , melena , vaginal bleeding , and somnolence ( table 1 ) . she received oral ribavirin 5 days after the incident , which possibly had limited effect because her illness already had progressed to confusion and gastrointestinal bleeding . a patient with cchfv infection and a high viral load ( 10 copies / ml ) was hospitalized with hemoptysis , hematemesis , melena , epistaxis , and intraalveolar bleeding . after the intervention , the other otorhinolaryngology resident handled and cleaned a head mirror without using gloves , although he was not in face - to - face contact with the patient . the infectious diseases resident resuscitated the patient without apparent direct contact with the patient s bloody secretions . for the 3 residents , fever , malaise , and myalgia developed 25 days after exposure . no contact was observed between the patient and the hcws , but the rna sequences from the patients and hcws were identical by molecular techniques . the transmission of cchfv could have resulted from indirect contact with contaminated devices , such as the head mirror ; the improper removal of gowns , masks , gloves ; inadequate hand hygiene ; or failure to use n95 masks during aerosolizing procedures . during the procedures that could generate aerosols , hcws should wear an n95 mask or ffp2 respirator ( 13 ) . the patients with higher viral load were reported to be more severe disease ( 14 ) . in 2008 , a phlebotomist working in a children s hospital had a needlestick injury during phlebotomy of a cchfv - infected child . his severity score index was moderate , and he recovered . a nurse in 2007 and a pediatric resident in 2008 incurred needlestick injuries during phlebotomy of a cchfv - infected patient . postexposure prophylaxis with ribavirin was started immediately after the injuries , and no infections developed . in 2005 , cchfv infection was diagnosed in a woman on the day of delivery by cesarean section . she was transferred to idcm , and her baby was transferred to the newborn service at the dr . a nurse in idcm , who had fever and myalgia , was later found to have cchfv infection ( table 1 ) . transmission was related to the improper use of gloves during the care of the mother s surgical wound . a nurse in the neonatal clinic in the children s hospital also acquired cchfv infection , which was attributed to the intubation and aspiration of bloody secretions from the baby without proper use of gloves and mask . the second nurse s illness was mild ; because she had a potential for getting pregnant , ribavirin was not started . both nurses recovered completely ( table 2 ) . * hcw , health care worker ; ast , aspartate aminotransferase ; alt , alanine aminotransferase ; aptt , activated partial thromboplastin time ; ssi , severity score index . < 50 iu / l ; alt , < 50 iu / l ; aptt , 2436 sec ; fibrinogen , 200400 mg / dl . serum samples from 37 hcws at idcm and the obstetrics and newborn clinics at the children s hospital who were at risk for infection were investigated for cchf . in addition to the 2 nurses , 2 nurses from the neonatal clinic were cchf igm positive but were asymptomatic . in 2006 , a nurse received a needlestick injury during a phlebotomy of a cchfv - infected patient . she was using gloves but no gown , and the needle stuck to her forearm . the nurse s symptoms began 2 days after the incident , and she was transferred to idcm 4 days after the incident . at admission , she had ecchymosis , epistaxis , hematemesis , melena , vaginal bleeding , and somnolence ( table 1 ) . she received oral ribavirin 5 days after the incident , which possibly had limited effect because her illness already had progressed to confusion and gastrointestinal bleeding . in 2008 , a patient with cchfv infection and a high viral load ( 10 copies / ml ) was hospitalized with hemoptysis , hematemesis , melena , epistaxis , and intraalveolar bleeding . after the intervention , the other otorhinolaryngology resident handled and cleaned a head mirror without using gloves , although he was not in face - to - face contact with the patient . the infectious diseases resident resuscitated the patient without apparent direct contact with the patient s bloody secretions . for the 3 residents , fever , malaise , and myalgia developed 25 days after exposure . no contact was observed between the patient and the hcws , but the rna sequences from the patients and hcws were identical by molecular techniques . the transmission of cchfv could have resulted from indirect contact with contaminated devices , such as the head mirror ; the improper removal of gowns , masks , gloves ; inadequate hand hygiene ; or failure to use n95 masks during aerosolizing procedures . during the procedures that could generate aerosols , hcws should wear an n95 mask or ffp2 respirator ( 13 ) . the patients with higher viral load were reported to be more severe disease ( 14 ) . in 2008 , a phlebotomist working in a children s hospital had a needlestick injury during phlebotomy of a cchfv - infected child . a nurse in 2007 and a pediatric resident in 2008 incurred needlestick injuries during phlebotomy of a cchfv - infected patient . postexposure prophylaxis with ribavirin was started immediately after the injuries , and no infections developed . six of the 9 cchf - infected hcws reported here had histories of needlestick injuries or contact with contaminated blood without adequate barrier precautions . an integrated strategy for controlling accidental exposure to body fluids all personnel , including cleaning staff in health care units on all shifts were informed and trained about the transmission risks , protection , and clinical symptoms of cchf ( 13 ) . the standard , contact , and droplet precautions were usually sufficient to protect against cchfv infection during the routine care of cchf patients . in addition to the practices of previous years , the airborne infection isolation precautions during aerosol - generating procedures were performed . after all of these measures were enforced , occupational cchfv infection did not occur in idcm . ribavirin is an effective treatment for cchfv infection ( 12 ) and beneficial for postexposure prophylaxis ( 13,15 ) . reported here who received ribavirin for postexposure prophylaxis , no symptoms developed ; similar reports will be useful for increasing the power of this conclusion . we used a ribavirin dosage of 2g / day , but no consensus exists about the dosage for postexposure prophylaxis .
we investigated 9 cases of crimean - congo hemorrhagic fever ( 1 fatal , 2 asymptomatic ) among health care workers in turkey . 
 needlestick injuries were reported for 4 workers . 
 eight received ribavirin . 
 in addition to standard precautions , airborne infection isolation precautions are essential during aerosol - generating procedures . for postexposure prophylaxis and therapy , 
 ribavirin should be given .