The challenge in Iraq
Crimean-Congo haemorrhagic fever (CCHF) is a severe viral disease that can be transmitted to humans through the bite of infected ticks or contact with the blood and tissue of infected animals. The disease is characterized by fever, muscle aches, headache and bleeding and has a high fatality rate, ranging from 10%–40%.
In Iraq, CCHF is a significant public health concern. Cases have been reported sporadically since 1979 and there has been a steady increase in recent years due to factors that include climate change, changes in agricultural practices and increased human-animal interactions.
Between 2020 and 2021, Iraq experienced its largest CCHF outbreak to date with over 300 confirmed cases by early 2022. The outbreak was exacerbated by unregulated livestock movement, intensified farming practices and the impact of the COVID-19 pandemic on health care resources.
Recognizing the urgent need for effective preventive measures in the absence of a licensed vaccine or targeted antiviral therapy for CCHF, the World Health Organization (WHO) Country Office in Iraq, in collaboration with the ministries of health and agriculture and the Iraqi Red Crescent Society, implemented a comprehensive risk communication and community engagement (RCCE) campaign.
The campaign aimed to reduce CCHF transmission by empowering high-risk populations with the knowledge and tools to protect themselves, and by strengthening the capacity of public health authorities to implement evidence-based RCCE strategies tailored to vulnerable groups.
WHO recognizes the importance of RCCE – a core capacity of the International Health Regulations (2005), the legally binding framework for preventing the international spread of disease – in controlling outbreaks. Public health interventions emphasize early awareness, vector control (efforts to control or eliminate the insects and arachnids, like ticks, that spread disease) and personal protective measures, particularly among high-risk occupational groups such as butchers, farmers, veterinarians and health care workers.
A multifaceted approach to communication
The campaign was rolled out across Iraq, with a focus on reaching vulnerable communities. A key aspect of the roll out was its integration with mass gathering health risk management, particularly during the Arbaeen pilgrimage, the annual religious gathering which draws over 20 million participants and increases the risk of disease transmission. To enhance effectiveness, a multisectoral response team was established, involving the WHO Country Office in Iraq, the ministries of health and agriculture and the Iraqi Red Crescent Society.
Multi-disciplinary teams composed of experts from these organizations were deployed to high-risk governorates to engage directly with at-risk populations. They utilized a variety of culturally and linguistically appropriate materials, including animated videos, infographics and radio dramas, designed to resonate with diverse audiences, including farmers, livestock traders, community leaders and health care workers. Materials were developed in multiple languages, including Arabic, Kurdish and Iraqi dialects, to ensure they were accessible to target groups.
To ensure messages were effectively tailored, the teams conducted focus group discussions and knowledge assessments, using behavioural change models like the Health Belief Model (which focuses on individuals' perceptions of risks and benefits) and the COM-B model (which emphasizes capability, opportunity and motivation), to inform their approach. The national RCCE campaign leveraged a variety of communication channels, including digital platforms like Instagram, YouTube and TikTok, alongside traditional in-person engagement to reach diverse audiences. It harnessed the power of social media and partnered with faith-based organizations, tribal elders and social media influencers to amplify messaging, broaden the reach of awareness campaigns and build trust within communities.
Engaging religious and tribal leaders in health promotion efforts has been a game changer. Their role in influencing behavioural change cannot be overstated
Capacity-building workshops were conducted for more than 4500 faith leaders and 9000 frontline responders. RCCE teams integrated their activities within One Health surveillance systems – recognizing their interconnectedness, the One Health approach aims to sustainably optimize the health and well-being of humans, animals and the environment – to ensure timely reporting and response mechanisms for suspected CCHF cases and facilitate a coordinated and efficient response to potential outbreaks.
Public health education played a crucial role in raising awareness and promoting preventive behaviours against CCHF. Over 250 community volunteers were trained to conduct door-to-door awareness campaigns, reaching over 139 000 people in 572 high-risk areas across 11 governorates.
Overcoming challenges, building resilience
The campaign faced several challenges. Teams had to navigate geographical and environmental obstacles, including extreme heat and sandstorms, which significantly impacted field deployment in remote areas. Cultural perceptions and misinformation were addressed by encouraging trusted community figures to lead sensitization efforts and counteract misconceptions about CCHF. The COVID-19 pandemic posed an additional challenge, diverting resources and attention and creating competing public health priorities that strained the resources available for emerging infectious diseases like CCHF.
Despite the challenges the campaign pushed ahead, driven by strong multisectoral coordination, evidence-based behaviour change models and a data-driven approach that allowed for real-time monitoring and adaptive message adjustment.
Key drivers of the campaign’s success included strong multisectoral coordination. Collaboration between the WHO Country Office in Iraq, the ministries of health and agriculture and the Iraqi Red Crescent Society helped ensure coordinated messaging and broad outreach which was reinforced by leveraging social learning theory, using trusted community figures to enhance credibility and message uptake, alongside the Health Belief and Com-B models.
As part of the data-driven approach, RCCE teams conducted real-time monitoring and community feedback assessments to adjust messages dynamically. Key components of the data-driven approach included:
Digital analytics
Utilized to monitor engagement and reach across social media platforms, tracking video views, shares and comments to assess message penetration and effectiveness.
Community surveys
Conducted before and after the intervention to evaluate changes in knowledge, attitudes and practices related to CCHF prevention.
Field monitoring
RCCE teams conducted spot-checks and structured interviews with high-risk populations to ensure message retention and behavioural adoption.
Epidemiological surveillance
Trends in reported CCHF cases were analysed before, during and after intervention activities to assess overall impact.
Impact and the road ahead
The epidemic curve plateaued 22 weeks after the first reported case, indicating a slowing of transmission. There was a marked increase in the adoption of preventive practices such as hand hygiene and the use of personal protective equipment among high-risk groups. Early health care-seeking behaviour also improved, leading to fewer severe cases and hospitalizations.
The use of risk communication in controlling CCHF has shown that when communities are empowered with knowledge, they can significantly reduce disease transmission through behaviour change
The campaign demonstrated the effectiveness of community-driven communication in mitigating public health crises. It fostered trust and collaboration between communities, health authorities and international organizations, contributing to a more resilient public health system in Iraq.
RCCE not only helped in building trust among communities across Iraq but increased their sense of ownership and accountability to take action to address health hazards
Building on these achievements, WHO Iraq and the Ministry of Health plan to scale up RCCE efforts for other vector-borne and zoonotic diseases, integrating lessons learned into Iraq's One Health strategy. The fight against CCHF is ongoing but the campaign has provided valuable experience and a proven model for community-driven prevention.
Impact and key indicators of success
RCCE interventions significantly improved public health outcomes through a combination of digital campaigns, direct outreach and targeted risk reduction strategies. These interventions directly influenced behavioural change, reduced disease transmission and enhanced preparedness for mass gatherings.
Coverage indicator: expanding reach and awareness
15 million people were reached through digital awareness campaigns across multiple platforms, including social media, radio, television and community networks. These campaigns disseminated critical information about preventive measures, early symptom recognition and vaccination promotion, ensuring widespread awareness.
One million high-risk individuals – including health care workers, livestock handlers and religious pilgrims – were engaged through direct community outreach programmes. These initiatives leveraged peer educators, local influencers and frontline health workers to ensure that high-risk populations had access to tailored, culturally sensitive health information.
Outcome indicator: behavioural change and epidemic control
The epidemic curve plateaued 22 weeks after the first reported case, indicating that RCCE interventions played a critical role in slowing transmission and stabilizing the outbreak. This trend highlights the effectiveness of timely and consistent public health messaging in controlling disease spread.
A measurable increase in the adoption of preventive practices was observed among livestock workers and religious pilgrims who were identified as key at-risk groups. Post-intervention surveys showed that:
hand hygiene compliance improved by 65% among livestock workers;
use of personal protective equipment among high-risk occupational groups increased by 47%; and
early health care-seeking behaviour for symptomatic individuals rose by 35%, reducing severe cases and hospitalization rates.
These changes significantly reduced transmission risk and improved public health resilience in high-exposure settings.
Cost-effectiveness indicator: maximizing impact with limited resources
More than 40 000 dedicated RCCE hours were spent on risk reduction activities during mass gatherings, including:
pre-event health education for pilgrims, traders and transport workers;
deployment of rapid response teams for rumour management and misinformation control; and
field mobilization of community health workers to enhance local engagement.
By leveraging digital platforms, community networks and cost-effective communication tools, the intervention achieved a cost-per-person-reached ratio 40% lower than traditional outbreak response campaigns, maximizing impact with minimal resource expenditure.
These findings highlight the tangible benefits of strategic RCCE implementation, including improved health literacy, reduced outbreak severity and cost-efficient public health interventions. The results highlight the importance of scalable, adaptable and community-driven communication approaches in managing health crises effectively.
Partners
The success of the intervention was made possible through the collaborative efforts of the following key partners:
WHO Country Office Iraq led the coordination, RCCE strategy development and implementation of the intervention;
Ministry of Health Iraq provided epidemiological surveillance, public health messaging and frontline health response;
Ministry of Agriculture Iraq assisted in vector control efforts, livestock monitoring and engagement with farmers and butchers;
Iraqi Red Crescent Society facilitated community outreach, volunteer training and direct engagement with high-risk populations;
faith-based organizations and tribal leaders played a crucial role in disseminating messages and fostering trust within communities; and
local media and social media influencers helped amplify health messages through digital and traditional media channels.
Funding and cost
This intervention was funded by the WHO Country Office in Iraq. The total cost of the intervention was between US$ 150 000 and US$ 200 000.
Resources and additional information
Annual statistical report. Baghdad: Ministry of Health; 2021 (https://moh.gov.iq/upload/1540.pdf).
Communicating risk in public health emergencies: a WHO guideline for emergency risk communication policy and practice. Geneva: World Health Organization; 2017 (https://www.who.int/publications/i/item/9789241550208) .
Communicating with communities in epidemics and pandemics: risk communication and readiness kit. Washington, D.C.: USAID and Global Readiness for Major Disease Outbreak Response; 2022 (https://www.ready-initiative.org/wp-content/uploads/2022/06/RCCE-Kit_15June-202222-1.pdf).
Community engagement and accountability toolkit. Geneva: International Federation of Red Cross and Red Crescent Societies; 2020 (https://www.ifrc.org/document/cea-toolkit).
Coronavirus disease (COVID-19) technical guidance: risk communication and community engagement. Geneva: World Health Organization; 2020 (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/risk-communication-and-community-engagement/).
COVID 19 strategic preparedness and response: monitoring and evaluation framework. Geneva: World Health Organization; 2020 (https://www.who.int/docs/default-source/coronaviruse/who-ncov-me-framework-web.pdf).
Crimean-Congo haemorrhagic fever: annual epidemiological report for 2022. Stockholm: European Centre for Disease Prevention and Control; 2024 (https://www.ecdc.europa.eu/en/publications-data/crimean-congo-haemorrhagic-fever-annual-epidemiological-report-2022).
Crisis and emergency risk communication manual. Atlanta: Centers for Disease Control and Prevention; 2018 (https://www.cdc.gov/cerc/php/cerc-manual/index.html).
Early warning systems for disease outbreaks. (https://www.emro.who.int/health-topics/ewarn/index.html).
Introduction to Crimean-Congo haemorrhagic fever: managing infectious hazards. Geneva: World Health Organization; 2013 (https://cdn.who.int/media/docs/default-source/documents/health-topics/crimean-congo-haemorrhaigc-fever/introduction-to-crimean-congo-haemorrhagic-fever.pdf).
Joint evaluation of the risk communication and community engagement collective service: evaluation report. Geneva: World Health Organization; 2024 (https://www.who.int/publications/m/item/joint-evaluation-of-the-risk-communication-and-community-engagement-(rcce)-collective-service--evaluation-report).
Large outbreak of Crimean-Congo haemorrhagic fever in Iraq, 2022. IJID Regions Open Access; 2023 (https://pmc.ncbi.nlm.nih.gov/articles/PMC9931897/pdf/main.pdf).
Risk communication and community engagement action plan guidance COVID-19 preparedness and response. Geneva: International Federation of Red Cross and Red Crescent Societies; New York: United Nations Children’s Fund; Geneva: World Health Organization: 2019 (https://www.who.int/publications/i/item/risk-communication-and-community-engagement-(rcce)-action-plan-guidance).
Risk communication and community engagement as an emerging pillar of health emergency management in Iran: achievements and the way forward. Geneva: Frontiers in Public Health; 2023 (https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2023.1097932/full).
Risk communication and community engagement capacity in the Eastern Mediterranean Region: a call for action. London: BMJ Global Health; 2024 (https://gh.bmj.com/content/7/Suppl_3/e008652).
Risk communication and community engagement during COVID-19. International Journal of Disaster Risk Reduction; 2022 (https://pmc.ncbi.nlm.nih.gov/articles/PMC8925315/pdf/main.pdf).
Risk communication and community engagement readiness and response toolkit: mpox. Geneva: World Health Organization; 2024 (https://www.who.int/publications/i/item/9789240091559).
Risk communication. Geneva: World Health Organization (https://www.who.int/emergencies/risk-communications).
