Viral Haemorrhagic Fever Policy

VIRAL HAEMORRHAGIC FEVER POLICY

Version / 1
Name of responsible (ratifying) committee / Infection Prevention Management Committee
Date ratified / 28 January 2015
Document Manager (job title) / Consultant Infection Prevention
Date issued / 12 February 2015
Review date / 31January 2017
Electronic location / Infection Control Policies
Related Procedural Documents / Hand Hygiene, Standard Precautions, Isolation, Linen and Laundry, Waste.
Key Words (to aid with searching) / Viral Haemorrhagic Fever, VHF, Ebola, Lassa, Congo-Crimean, Marburg

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
1 / 14/01/2015 / New document / IPCT

CONTENTS

QUICK REFERENCE GUIDE

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5. DUTIES AND RESPONSIBILITIES

6. PROCESS

7. TRAINING REQUIREMENTS

8. REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

11.APPENDIX 1

QUICK REFERENCE GUIDE

1. VHF must be considered for any patient presenting with undiagnosed fever≥37.5°C or a history of fever in the past 24 hourswithin 21 days of returning from an endemic area or having an epidemiological exposure to VHF.

The VHF Risk Assessment and Advisory Committee on Dangerous Pathogens ‘Management of Hazard Group 4 viral haemorrhagic fevers’ can be found here:

2. Patients categorised as ‘UNLIKELY to have a VHF infection’ -

Patients with a fever ≥37.5°Cor a history of fever in the past 24 hours who are highly unlikely to have a VHF infection if:

They have not visited a VHF endemic area within 21 days of becoming ill;
They have not become unwell within 21 days of caring for or coming into contact with the bodily fluids of / handling clinical specimens from a live or dead individual or animal known or strongly suspected to have a VHF;
If their UK malaria screen is negative and they are subsequently afebrile for >24 hours;
If their UK malaria screen is positive and they respond to malaria treatment;
If they have a confirmed alternative diagnosis and are responding appropriately1

3. Patients categorised as ‘LOW POSSIBILITY of VHF infection’ -

Patients may be classified as Low Possibility of VHF infection if:

They have a fever ≥37.5°Cor a history of fever in the past 24 hours who and have been in an endemic area during the 21 days before the onset of illness BUT
have none of the additional risk factors that place them in the high risk category (see appendix 1) AND HAVE NOT
cared for/come into contact with body fluids of/handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF within the past 21 days1

4. Patients categorised as ‘HIGH POSSIBILITY of VHF infection’ -

Includes febrile patients with a fever ≥37.5°Cor a history of fever in the past 24 hours who:

a) Have been in an endemic area during the 21 days before illness and

have lived or worked in basic rural conditions in an area where Lassa Fever is endemic? OR

have visited caves / mines, or had contact with or eaten primates, antelopes or bats in a Marburg / Ebola endemic area? OR
have travelled in an area where Crimean-Congo Haemorrhagic Fever is endemic AND sustained a tick bite or crushed a tick with their bare hands OR had close involvement with animal slaughterOR

were previously categorised as “low possibility” but who have developed organ failure and/or haemorrhage.1

b) Have not been in an endemic area but during the 21 days before illness they

cared for/came into contact with body fluids of/handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF1

5. Contact details:

Portsmouth Hospitals On-call Microbiology or Infection Prevention Team / Via Portsmouth Hospitals Switchboard
High Security Infectious Disease Unit, Royal Free, London (24 hrs, ask for infectious disease physician on call) / 020 7794 0500 or 0844 8480700
Public Health England (Wessex Centre) CCDC / In Hours 0345 055 2022
OOH 0844 9670082
Imported Fever Service / 0844 778 8990

1.INTRODUCTION

The Viral Haemorrhagic Fevers (VHF’s) are severe and life-threatening viral diseases that have been reported in parts of Africa, South America, the Middle East and Eastern Europe. VHFs;

can spread within a hospital setting;
have a high case-fatality rate;
are difficult to recognise and detect rapidly;
have no effective, definitive treatment1.

Environmental conditions in the UK do not support the natural reservoirs or vectors of any of the haemorrhagic fever viruses, and all recorded cases of VHF in the UK have been acquired abroad, with the exception of one laboratory worker who sustained a needle-stick injury.

VHF must be considered for any patient presenting with undiagnosed fever within 3 weeks of returning from an endemic area (see appendix 1)2.

This guidance covers four VHFs which may (rarely) present either in the Emergency Department (ED) or via a local General Practitioner (GP).

Lassa fever
Marburg fever
Ebola fever
Congo-Crimean haemorrhagic fever

All four are severe, highly infectious, life threatening diseases, although there are other VHF’s of less severity e.g. Yellow fever virus and Dengue virus. Further information on the viruses classified as Advisory Committee on Dangerous Pathogens (ACDP) hazard group 4 viruses can be found here:

2.PURPOSE

The purpose of this policy is to provide guidelines on the assessment and management of patients with suspected or confirmed viral haemorrhagic fevers (VHF).

3.SCOPE

This Policy applies to all staff employed by Portsmouth Hospitals NHS Trust (the Trust) or Carillion, and also to all visiting staff including staff from external agencies (e.g. CCG or other Trusts), tutors, students, agency/locum staff and contractors.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4.DEFINITIONS

Category A waste - an infectious substance that is transported in a form that, when exposure to it occurs, is capable of causing permanent disability, life-threatening or fatal disease to humans or animals. Wherever possible, Category A waste should be treated on- site using an autoclave or equivalent before being transported for disposal3.

Category B waste - an infectious substance that does not meet the criteria for inclusion in Category A3.

Viral haemorrhagic fevers - a group of illnesses that are caused by several distinct families of viruses e.g. Ebola, Lassa fever, Crimean Congo haemorrhagic fever, Dengue fever, Yellow fever.

Crimean-Congo haemorrhagic fever (CCHF) - is transmitted through the bite of an infected tick, contamination with tick body contents, or direct contact with the blood, tissues or body fluids of infected humans or animals. The incubation period varies according to the mode of acquisition of the virus; tick bite: usually 1-3 days, and up to 9 days; infection via contact with infected blood or tissues: 5-6 days: maximum recorded incubation period is 13 days.

The illness begins abruptly, with fever, muscle aches, dizziness, neck pain and stiffness, backache, headache, sore eyes and photophobi. Nausea, vomiting and sore throat may also occur, with diarrhoea and abdominal pain. Over the next few days the patient may experience mood swings, confusion and aggression, followed by sleepiness, depression and liver enlargement. More severe symptoms may follow, including petechial rash, bruising and generalised bleeding of the gums and orifices. In severe cases patients develop failure of the liver, kidneys and lungs, and become drowsy and comatose after 5 days. Approximately 30% of cases are fatal.4

Ebola virus disease - (formerly known as Ebola haemorrhagic fever) is believed to be a zoonotic disease, however the natural reservoir is unknown. The first human case in an outbreak of Ebola is acquired through contact with blood, secretions organs or other bodily fluids of an infected animal. The virus is then transmitted to others through direct contact with the blood, secretions, organs or other bodily fluids of infected persons. The incubation period of Ebola virus disease ranges from 2 to 21 days. The onset of illness is sudden, with fever, headache, joint and muscle pain, sore throat and intense weakness. This is then followed by diarrhoea, vomiting, rash, impaired kidney and liver function and stomach pain. Some patients may develop a rash, red eyes, hiccups, internal and external bleeding. Ebola haemorrhagic fever is fatal in between 50-90% of all clinically ill cases.4

Lassa Fever - transmission of Lassa virus to humans normally occurs through contamination of broken skin or mucous membranes via direct or indirect contact with infected rodent excreta. Person to person transmission occurs through exchange of infected bodily fluids, such as blood, saliva, urine or semen. Infection is mild or asymptomatic in 80% of cases, but can cause severe illness and is fatal in approximately 1-3% of patients. The incubation period for disease is usually between 7 and 10 days, although a range of 3-21 days has been reported in some cases. The onset of illness is insidious, with fever and shivering accompanied by malaise, headache, generalised aching and a sore throat. This may be accompanied by nausea, vomiting, diarrhoea or cough. There may be patches of white or yellowish exudate and occasionally small vesicles or shallow ulcers on the tonsils and pharynx and this is an important diagnostic feature. Fever is very variable, occurring constantly or in peaks, and lasting on average for 16 days; extremes of 6-30 days have been reported.Severe attacks are characterised by extreme lethargy and exhaustion, disproportionate to the level of fever. During the second week of illness there may be oedema of the head and neck, encephalopathy, pleural effusion, and ascites. Renal and circulatory failure may occur, aggravated by vomiting and diarrhoea. In the severest cases bleeding into the skin, mucosae and deeper tissues occurs, usually leading to death.Infection is fatal in around 15% of hospitalised patients. Lassa fever is particularly severe in pregnant women in the third trimester; the foetus dies in about 95% of cases.4

Marburg virus - clinically almost indistinguishable from Ebola virus disease. Fruit batsare considered the natural host of the virus. The incubation period is 3-10 days. The onset of illness is sudden, with severe headache, malaise and high fever, with progressive and rapid debilitation. This is followed by watery diarrhoea, abdominal pain, cramping, nausea and vomiting by about the third day. Symptoms become increasingly severe, and many patients develop severe haemorrhagic fever after 5-7 days. Fatal cases usually have bleeding, which is often from multiple sites. The initial infection is acquired through exposure in mines or caves inhabited by Rousettus bat colonies. Subsequent transmission of virus from person to person requires close contact with an infected patient with transmission through contact with blood or other bodily fluids (faeces, vomit, urine, saliva and respiratory secretions) containing a high concentration of virus, particularly when these fluids contain blood.4

5. DUTIES AND RESPONSIBILITIES

Chief Executive is responsible for ensuring the Trust has an appropriate policy in place to appropriately care for patients with VHF;

Infection Prevention and Control Team are responsible for providing support and advice;

Medical Microbiology are responsible for co-ordinating laboratory samples and conducting a risk assessment for patients suspected of VHF;

All Clinical Staff are responsible for complying with all aspects of this policy;

Laboratory staff are responsible for recording and processing specimens and for the appropriate reporting of results to the relevant areas and staff.

6. PROCESS

6.1 Diagnosis - In the early stages of the illness there may be no specific clinical features so VHF must be considered for any patient presenting with undiagnosed fever within 21 days of returning from an endemic area or having an epidemiological exposure to VHF.

Other clinical features may include:

Chills
Malaise
Headaches
Myalgia
Pharyngitis
Diarrhoea
Bloody diarrhoea

Vomiting,
Rash
Bleeding
Shock
Lymphopaenia
Thrombocytopaenia
Raised AST.

Refer to the Viral Haemorrhagic Risk Assessment (appendix 1) for clinical history and additional questions.2

Refer to for current endemic areas.5

6.2 Communication - If the possibility of VHF is raised, the clinician must consult a consultant microbiologist to discuss whether the patient can be admitted and investigated locally or whether transfer to the High Security Infectious Disease Unit (HSIDU) at The Royal Free Hospital is required.

The Consultant in Infection Prevention (in hours) or the on-call Infection Prevention Team must also be immediately notified of any suspected VHF infection.

The Consultant for Communicable Disease Control (CCDC) must be notified urgently by telephone of any patient categorised as HIGH POSSIBILITY of VHF’.

6.3 Infectivity - Dependant on the virus, modes of transmission can include blood, urine, semen, vomit, faeces and tick body contents. There has been no evidence of aerosol transmission from VHF patients. Patients can be managed more effectively if they are categorised according to level of infectivity and risk:

6.3.1 Patients categorised as ‘UNLIKELY to have a VHF infection’ -

Patients with a fever ≥37.5°Cor a history of fever in the past 24 hours who are highly unlikely to have a VHF infection if:

They have not visited a VHF endemic area within 21 days of becoming ill;
They have not become unwell within 21 days of caring for or coming into contact with the bodily fluids of / handling clinical specimens from a live or dead individual or animal known or strongly suspected to have a VHF;
If their UK malaria screen is negative and they are subsequently afebrile for >24 hours;
If their UK malaria screen is positive and they respond appropriately to malaria treatment;
If they have a confirmed alternative diagnosis and are responding appropriately1

The risk of VHF in the patient should be reassessed if a patient with a relevant exposure history fails to improve or develops one of the following:

Nosebleed;
Bloody diarrhoea;
Sudden rise in aspartate transaminase (AST);
Sudden fall in platelets;
Clinical shock;
Rapidly increasing O2requirements in the absence of other diagnosis.1

6.3.2 Patients categorised as ‘LOW POSSIBILITY of VHF infection’ -

Patients may be classified as Low Possibility of VHF infection if:

They have a fever ≥37.5°Cor a history of fever in the past 24 hours who and have been in an endemic area during the 21 days before the onset of illness

BUT

have none of the additional risk factors that place them in the high risk category (see appendix 1)

AND HAVE NOT

cared for/come into contact with body fluids of/handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF within the past 21 days1

6.3.3 Patients categorised as ‘HIGH POSSIBILITY of VHF infection’ -

Includes febrile patients with a fever ≥37.5°Cor a history of fever in the past 24 hours who:

a) Have been in an endemic area during the 21 days before illness and

have lived or worked in basic rural conditions in an area where Lassa Fever is endemic? (

have visited caves / mines, or had contact with or eaten primates, antelopes or bats in a Marburg / Ebola endemic area? ( haemorrhagic-fevers-outbreaks-and-case-locations

have travelled in an area where Crimean-Congo Haemorrhagic Fever is endemic ( AND sustained a tick bite or crushed a tick with their bare hands OR had close involvement with animal slaughter

were previously categorised as “low possibility” but who have developed organ failure and/or haemorrhage.1

b) Have not been in an endemic area but during the 21 days before illness they

cared for/came into contact with body fluids of/handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF1

Infection Prevention and Control Measures

6.4 A patient categorised as ‘UNLIKELY to have a VHF infection’ should be admitted if ill and requiring hospital treatment, under STANDARD ISOLATION procedures to Portsmouth Hospitals. Also see Trust policies: Hand Hygiene; Standard Precautions; Isolation.1

6.5 A patient categorised as ‘LOW POSSIBILITY of VHF’ should be isolated in a single side room immediately to limit contact until the possibility of VHF has been ruled out. The room should also have dedicated en-suite facilities or at least a dedicated commode.

Staff should implement standard precautions as appropriate. The level of any additional staff protection is dependent on the patient’s symptoms as follows:1

Infection control measures for ‘Low possibility of VHF’
Standard Precautions:

hand hygiene
gloves

plastic apron

Additional protection for splash inducing procedures

fluid repellent surgical facemask
eye protection

It is recommended that, if a patient is bruised or bleeding, the lead clinician should have an urgent discussion with the nearest High Security Infectious Disease Unit at the Royal Free Hampstead NHS Trust, London (see communication 6.2).1

Single use (disposable) equipment and supplies should be used. The use of a needle-free intravenous system to eliminate the risk of needlestick injuries should also be considered.

6.5.1 Waste - should be handled as infectious and placed in the orange waste bags for normal disposal by incineration.

6.5.2 Laundry - should be treated as infectious, and packaged using a red water soluble bag inside a red linen bag.

6.5.3 Cleaning and Decontamination - should be performed as normal with hypochlorite containing 1,000ppm available chlorine or chloride dioxide solution.

6.5.4Staff Information - Staff must be informed about and understand the risks associated with a VHF patient, for example:

The severity of a VHF if infection is confirmed;
That virus may be present: in blood; body fluids including urine; waste; on contaminated instruments and equipment; on contaminated clothing; on contaminated surfaces.
That exposure to virus may occur:
- directly, through exposure (broken skin or mucous membranes) to blood and/or body fluids during invasive, aerosolising or splash procedures;
- indirectly, through exposure (broken skin or mucous membranes) to environments, surfaces, equipment or clothing contaminated with splashes or droplets of blood or body fluids.1

6.6 Diagnostic specimens / investigations in patients categorised as ‘LOW POSSIBILITY of VHF’ -