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Background: Crimean Congo haemorrhagic fever (CCHF) is an emerging zoonotic infection with high mortality. Nosocomial spread is described secondary to body fluid contact., Methods: Patients meeting the case definition for viral haemorrhagic fever (VHF) from August to November 2019 were tested for CCHF after ruling out dengue, malaria, scrub typhus and leptospirosis in a tertiary teaching hospital in western Rajasthan, India. Diagnosis was confirmed using both quantitative reverse transcription polymerase chain reaction and immunoglobulin M/immunoglobulin G enzyme-linked immunosorbent assay for all patients. All hospital contacts were line listed and tested and symptomatic high-risk contacts received ribavirin post-exposure prophylaxis. Cohorting, personal protective equipment use and hand washing were employed to prevent nosocomial spread., Results: Four patients tested positive for CCHF. We encountered uncommon initial presentations involving motor weakness and supraventricular tachycardia. Elevated serum lactate dehydrogenase and creatinine kinase were useful in clinical diagnosis. Only one patient survived despite ribavirin therapy. There was zero nosocomial transmission. A partial segment of nucleocapsid of amplified CCHF virus was 99.62% identical to the Afghanistan and Oman strains., Conclusions: The distribution of CCHF appears to be expanding, with CCHF emerging as endemic in Rajasthan, India. In this setting of high mortality, hand washing and PPE use prevented nosocomial transmission., (© The Author(s) 2020. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)