Management of Viral Haemorrhagic Fevers Policy
Management of Viral Haemorrhagic Fevers Management of Viral Haemorrhagic Fevers Policy Author: Health Protection Team Responsible Lead Executive Director: Director of Public Health Endorsing Body: Health Protection Committee Governance or Assurance Committee Clinical Governance Committee Implementation Date: October 2014 Version Number: V 2.0 Review Date: March 2017 Responsible Person Lindsay Guthrie Version No.2.0 October 2014 Page 1 of 25 Management of Viral Haemorrhagic Fevers CONTENTS 10) Consultation and Distribution Record ii) Change Record 10. INTRODUCTION 2. AIM, PURPOSE AND OUTCOMES 3. SCOPE 4. PRINCIPLE CONTENT 5. ROLES AND RESPONSIBILITIES 6. RESOURCE IMPLICATIONS 7. COMMUNICATION PLAN 8. QUALITY IMPROVEMENT – MONITORING AND REVIEW 9. EQUALITY AND DIVERSITY IMPACT ASSESSMENT 10. REFERENCES Appendix 1: VHF decision making algorithm (Sept 2014) Appendix 2: Patient Pathway Appendix 3: Infection Control Precautions – VHF Appendix 4: Categorisation and Management of Contacts Appendix 5: WHO (2014) Correct Method of putting on and removing PPE Version No.2.0 October 2014 Page 2 of 25 Management of Viral Haemorrhagic Fevers CONSULTATION AND DISTRIBUTION RECORD Contributing Author / Authors Consultation Process / Stakeholders: Distribution: Lindsay Guthrie, Senior Nurse Health Protection Josephine Pravinkumar, Consultant Public Health Medicine General Practitioners (GP) Infectious diseases consultant Emergency department consultant Consultant Microbiologist Haematologists Biochemistry laboratory staff Infection control staff Public Health PSSD Mortuary staff Scottish Ambulance Service Funeral Directors NHS Lanarkshire intranet – Firstport NHS Lanarkshire internet CHANGE RECORD Date 22/11/2013 10/02/2014 18/03/2014 20/02/2014 Change Content revised to reflect DoH guidance Final version for approval Updated to reflect updated ACDP guidance Updated to reflect Laboratory comments & updated guidance 01/04/2014 Lindsay Guthrie Final version for approval 28/04/2014 Lindsay Guthrie Updated to reflect SAS VHF policy – change to information re transfer of patients 17/07/2014 Lindsay Guthrie Updated to reflect updated HPS algorithm 28/08/2014 Josephine Updated to reflect updated ACDP guidance Pravinkumar 10/09/2014 Lindsay Guthrie Updated to reflect revised guidance 09/10/2014 Lindsay Guthrie Updated algorithm, guidance and to reflect comments from of table top exercise 14/10/2014 Josephine Updated guidance to reflect comments from Pravinkumar ID unit staff and exercise participants 17/10/2014 L Guthrie Interim version with further changes Version No.2.0 Author Lindsay Guthrie Lindsay Guthrie Lindsay Guthrie Lindsay Guthrie October 2014 Version No. V0.2 V1.0 V1.1 V1.2 V1.3 V1.4 V1.5 V1.6 V1.7 V1.8 & 1.9 V1.10 V2.0 Page 3 of 25 Management of Viral Haemorrhagic Fevers 1. INTRODUCTION This policy has been developed for use in NHS Lanarkshire as part of the Control of Infection policy manual. This policy should be read in conjunction with the following policy: Section 1 – Standard Infection Control Precautions 2. AIM, PURPOSE & OUTCOME To ensure that healthcare workers (HCWs) consider Viral Haemorrhagic Fever (VHF) as a possible diagnosis in patients with an indicative history and symptoms. To ensure that all HCWs take appropriate actions to minimise the risk of cross infection to themselves and others by urgent and appropriate referral in line with the guidance developed by the Department of Health. To ensure that all HCWs apply appropriate infection prevention and control precautions when providing care for patients with suspected or known infection with VHF. 3. 1 SCOPE This policy is designed to safeguard patients, staff and the wider public from the risk of VHF. The policy is aimed at healthcare staff working in NHS Lanarkshire, but particularly 3.2 Emergency Department staff Out of hours services General Practitioners Infectious diseases unit staff Laboratory staff Public Health professionals Mortuary and funeral services staff STAKEHOLDERS Infectious Diseases Consultant Emergency Department Consultant Consultant Microbiologist Infection Control Staff Department of Public Health General Practitioners PSSD Mortuary staff Scottish Ambulance Service Funeral Directors Version No.2.0 October 2014 Page 4 of 25 Management of Viral Haemorrhagic Fevers 4.1 VIRAL HAEMORRHAGIC FEVERS Viral Haemorrhagic fevers (VHF) are severe and life threatening diseases caused by a range of viruses. They are endemic in some parts of the world, particularly: Africa South America Middle East, and Eastern Europe. VHFs are of particular public health importance because: they can spread within a hospital setting they have a high case-fatality rate they are difficult to recognise and detect rapidly, and there is no effective treatment. Causative organisms Of 15 viral agents, 4 are more commonly known: Clinical manifestation Incubation period Period of infectivity Mode of transmission Reservoirs Population at risk Version No.2.0 Ebola (Filoviridae) Lassa (Arenaviridae) Crimean/Congo haemorrhagic fever caused by Nairovirus (Bunyaviridae) and Marburg Fever, headache, myalgia, pharyngitis, diarrhoea, vomiting, macropapular rash, bruising, bleeding, multi organ failure Up to 21 days (dependent on virus) Can be up to 61 days post onset. Virus can survive on surfaces for around 2 weeks, or longer on fabrics/soft furnishings People remain infectious as long as their blood and body fluids, including semen and breast milk, contain the virus e.g. for up to 7 weeks after recovery from illness Direct contact (through broken skin or mucous membrane) with blood or body fluids, and Indirect contact with environments contaminated with splashes or droplets of blood or body fluids There is no evidence of an aerosol transmission risk from VHF patients Exposure to patients prior to the onset of fever does not appear to carry the risk of transmission Bite of an infected tick or mosquito Animal/insect hosts No natural environmental reservoirs in UK Secondary infection risk from exposure to infected blood or body fluid Travellers, healthcare workers, laboratory staff 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. October 2014 Page 5 of 25 Management of Viral Haemorrhagic Fevers Notifiable disease 4.2 Yes PATIENT RISK ASSESSMENT A risk assessment of exposure to biological agents is a legal obligation under the Control of Substances Hazardous to Health (CoSHH) Regulations. It is the responsibility of the general practitioner, or admitting physician to recognise the risk of VHF. VHF infection is possible in any patient presenting with: a pyrexia of unknown origin, or a history of pyrexia within previous 24 hours, AND a travel history or epidemiological exposure within 21 days Other symptoms of concern would be: bruising or bleeding, uncontrolled diarrhoea or vomiting. When assessing a patient with fever who has a history suggestive of VHF, it is difficult to make a firm diagnosis solely on clinical grounds, therefore attention must be paid to epidemiological evidence e.g. travel to endemic areas, association with any known cases. A possible VHF case must fulfil the following conditions: A) The patient has a fever or history of fever in past 24 hours AND has returned from a VHF endemic country within 21 days OR B) The patient has a fever or history of fever in past 24 hours AND has 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? If any of the above conditions are fulfilled secure answers to the following questions: 1) Patient travelled to Guinea, Liberia, Sierra Leone, Congo DR, Nigeria or other countries where cases of Ebola / VHF have been reported during past 21 days? 2) Lived or worked in basic rural conditions? 3) Visited caves OR mines, or had contact with primates, antelopes or bats? 4) Sustained a tick bite, crushed a tick OR had close involvement with animal slaughter? If none of the four above apply then there is a LOW POSSIBILITY OF VHF. To assist clinical decision making, please see: APPENDIX 1 – VHF Risk Assessment Algorithm For up to date information on VHF risk maps see: Travax and WHO Global Alert Map Ebola Version No.2.0 October 2014 Page 6 of 25 Management of Viral Haemorrhagic Fevers Following initial assessment, and where VHF is considered, formal risk assessment MUST be carried out by the on-call Consultant Infectious Diseases (ID) physician [Contact via Monklands General Hospital switchboard: Telephone 01236 748 748] Following this assessment, patients will be classified as: Unlikely to have a VHF – answers no to questions A & B in Appendix 1-VHF risk assessment algorithm Low Possibility – fever AND history of travel to an endemic or outbreak country in past 21 days High possibility – fever AND has cared for/come into contact with body fluids of an individual or laboratory animal known or strongly suspected to have VHF OR answers yes to any additional question Confirmed VHF – any patient with a positive VHF screen A patient pathway is available as Appendix 2 to help determine the initial actions and precautions required to safely manage patient care and minimise the risk of infection to staff and the wider population. The ID Consultant physician will liaise with the Imported Fever Service at Public Health England to discuss VHF screening as appropriate: Telephone 0844 7788990 4.3 PATIENT MANAGMENT – INFECTION PREVENTION AND CONTROL It is assumed that ALL STAFF will observe standard infection control precautions (SICPs) at ALL TIMES with ALL PATIENTS, to minimise the risk of infection to staff and other patients. In addition to standard precautions, staff should also be familiar with, and practice the following Transmission Based Precautions (TBP’s): Contact precautions Droplet precautions Airborne precautions Personal Protective Equipment (PPE) must be worn by all staff caring for suspected VHF patients. This PPE must establish a barrier against contact with contaminated surfaces, splash, spray, bulk fluids and aerosol particles. It must also cover all exposed skin with sufficient integrity to prevent any ingress or seepage of liquids or airborne particles. Please see Appendix 3 for detailed advice on the infection control precautions required. Specific information for GP practices can be found on the Health Protection Team Firstport page. Version No.2.0 October 2014 Page 7 of 25 Management of Viral Haemorrhagic Fevers SPECIMEN HANDLING & LABORATORY PROCEDURE To minimise the risk of contamination to staff and patients, point of care/near patient testing equipment (e.g. blood gas analysers) should not be used to process samples from patients who are being assessed for VHF. All samples should be sent to the appropriate laboratories for processing and the laboratory staff advised of a possible diagnosis of VHF. There should be telephone confirmation once sample has been received by the labs. Routine biochemistry/haematology tests can be taken and sent (with prior notification) to the laboratories whilst awaiting the outcome of the malaria film. It is expected that any specimens from patients who are highly possible or known to have VHF, will only be requested following discussion with the ID Consultant. Test Highly possibility of VHF (with: bleeding bruising and/or uncontrolled vomiting or diarrhoea) URGENTLY – Should only be undertaken in the Class 1 Safety cabinet within lab Confirmed case of VHF VHF Screening Discuss with ID Consultant if malaria negative with continuing fever Discuss with ID Consultant if malaria negative Urgent VHF screening AFTER discussion with ID consultant N/A Routine laboratory diagnostic tests (suggested) Full blood count Full blood count Full blood count U&Es U&Es U&Es LFTs LFTs LFTs Glucose Clotting screen Clotting screen Patient would be transferred to the HLIU where further testing would be undertaken CRP CRP CRP Clotting screen Glucose Glucose Blood culture Blood culture Blood culture Malarial screen Note: Glucose measurement may be performed on the same yellow top tube being sent for U&E, CRP and LFT tests, and a separate grey top tube will not be required Low possibility of VHF Highly possibility of VHF N/A Stool culture Urine culture Version No.2.0 October 2014 Page 8 of 25 Management of Viral Haemorrhagic Fevers To minimise the risk to staff, the following must be observed: Laboratory staff MUST be informed of specimens PRIOR TO RECEIPT Specimen handling and storage should be kept to a minimum Vacutainer system must be used All specimens from cases with a high possibility of VHF must be appropriately labelled, double bagged and placed into a rigid PVC container (i.e. a bio bottle within an appropriate cardboard box) ¹ (obtained from the laboratory) for transport from A&E/ward to the laboratory Pneumatic tube system must not be used for the transport of samples to the laboratory Strict adherence to standard infection control precautions and laboratory procedures by all staff at all times. Clinical staff MUST inform the laboratory if the patient risk category changes during the period of admission. ¹ Rigid PVC UN marked container which meets the standard required by The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009 Specimen handling & laboratory procedures for VHF investigations Blood films must be prepared in Class 1 Microbiological Safety Cabinet within a Containment Level 3 laboratory (this is based on local laboratory risk assessment) Two trained observers are required for the diagnosis of malaria as recommended by ‘The Malaria Woking Party of the Haematology Task Force of the British Committee for Standardisation of Haematology’ The VHF risk should be identified at laboratory specimen reception (if it has not already been identified) and conveyed to senior staff in all the laboratory disciplines for whom samples have been received. A consultant microbiologist must be informed prior to any sample processing commencing. The Haematology on-call BMS must contact the on-call Microbiology BMS and advise on the need to use of Class 1 safety cabinet Only Haematology staff trained in the use of Containment Level 3 facilities should be admitted to those facilities Before commencement of processing sample, the Microbiology BMS must prepare the cabinet for use and supervise access to the CL3 laboratory and remain while the sample is being processed. All unnecessary equipment should be removed from the cabinet and a dedicated sharps bin placed within the cabinet. Access to materials required for decontamination should be immediately available within the cabinet. The Haematology BMS will prepare and assess blood samples to exclude malaria according to local protocol See Risk Assessment Number 4.2 for the treatment of resultant waste materials and for spillage procedures Version No.2.0 October 2014 Page 9 of 25 Management of Viral Haemorrhagic Fevers Retrieval of specimens If the possibility of VHF is realised after specimens have been sent, it is the responsibility of the CPHM to ensure that specimens are: Located quickly Made safe by autoclaving and incineration (Category A waste). OR If not for immediate disposal, packed in rigid containers, which should be surface decontaminated and retained within the laboratory awaiting safe disposal 4.5 VHF LABORATORY COMMUNICATION CASCADE On- call Microbiologist (notified by ID Consultant) On- call Microbiology BMS On-call Consultant Biochemist On- call Consultant Haematologist Microbiology safety officer (if required) On- call Biochemistry BMS On- call Haematology BMS 2nd On-call Haematology BMS 4.7 PATIENT TRANSPORT GP’s should not use 999 ambulance services to arrange hospital transfer of patients from the community. The Infectious Disease Consultant will arrange, with the SAS, for the transfer of any patients who are suspected of being infected with a VHF. VHFs are classified as Ambulance Category 4 infectious diseases across all Ambulance Services in the UK. Therefore, patients categorised as ‘low possibility’; ‘high possibility’ or ‘confirmed’ will require to be transferred in accordance with Scottish Ambulance Service (SAS) protocols. Only staff who have received specialist training are permitted to transport these cases. Ambulance control will coordinate the Special Operations Response Team (SORT). The decision to transfer a patient should be made by the Consultant in Infectious Diseases. Transfer to any unit outwith NHS Lanarkshire (e.g. Royal Free Hospital London High Level Isolation Unit (HLIU) will only be arranged following consultation and agreement with referring clinician or clinicians at the HLIU/other unit to which the patient is to be transferred. Version No.2.0 October 2014 Page 10 of 25 Management of Viral Haemorrhagic Fevers Consultant ID Call ambulance control - request ‘National Operations Manager’ Rapid teleconference - ID consultant/SAS/ referring doctor (+/CPHM - discuss patient risk category, medical and other requirements Special operations response team (SORT) team mobilised with 2 nd team following as back up. The ID Consultant is responsible for liaising with SAS to arrange emergency tertiary referral to the Royal Free Hospital, London HLIU. If an isolator is required (for confirmed cases) SAS SORT will liaise with North East Ambulance Service or London Ambulance Service to coordinate the provision of this. Transfer of a patient within the UK to an HLIU may be necessary when either: the patient has had a positive VHF screen result, OR the patient has been categorised as ‘high possibility of VHF’, AND has bruising or bleeding, OR uncontrolled diarrhoea or uncontrolled vomiting. The Director of Public Health of the patient’s health board of residence and the Scottish Government Health Department must be informed promptly of referral to the Royal Free Hospital, London HLIU. 4.7.1 INTERNAL TRANSFER OF PATIENTS Patients admitted via A&E may be required to be transferred internally to Ward 2 (MGH) Infectious Diseases Unit. ** Follow NHS Lanarkshire radiation procedure** 4.8 LAST OFFICES, POST MORTEM & GUIDANCE FOR FUNERAL STAFF Post Mortem: A post mortem examination on a person known to have died of VHF exposes staff to an unwarranted risk and should NOT be performed. Removal of pacemakers or implants should only be undertaken following discussion and agreement with the CPHM Version No.2.0 October 2014 Page 11 of 25 Management of Viral Haemorrhagic Fevers Body preparation/last offices: Hygienic preparation and embalming on a patient known to have died of VHF exposes staff to an unwarranted risk and should NOT be performed. Where the body of a confirmed or suspected VHF patient is not in an isolator, staff wearing suitable PPE should place the body inside either a separate CRBN standard (or equivalent) robust body bag (double bagged) with viewing panel Absorbent material should be placed between each bag, and the bag sealed and disinfected with 1000ppm available chlorine or other appropriate disinfectant. The bag should be labelled as high risk of infection The body bag should be placed in robust coffin with sealed joints. An infection control notification sheet should be completed for the funeral director (section O of CIM) Specific guidance for undertakers The person in charge of the mortuary has a statutory duty to protect people coming into contact with infected bodies, and family and funeral directors must be informed of the infection risk. The body bag/coffin must not be opened except if authorised by the Consultant in Public Health Medicine (CPHM), and then only by a person designated by them. Transportation of the body out of the country is not recommended. Following cremation, ashes may be safely transported. In the unlikely event of a VHF infected body being embalmed abroad and transported back to the UK, it would need to be contained within a sealed zinc lined transport coffin in accordance with International Air Transport Association IATA requirements. Return of personal effects The family of the deceased should be consulted and, as far as is reasonably practicable, their needs and wishes should be respected. In principle; clothing, personal effects and valuables may be returned to relatives in accordance with normal health service procedure following decontamination. Items of clothing visibly contaminated should be safely disposed of. Other items of clothing should be autoclaved prior to laundering. Wedding rings, jewellery and other physical artefacts should either be autoclaved or decontaminated using a validated disinfectant. With sensitivity and respect for the dignity of the bereaved, relatives should be alerted that some clothing fabrics and materials from which personal effects are made (e.g. plastics) may be adversely affected or even destroyed by autoclaving or disinfection (hypochlorite, the disinfectant of choice is a powerful bleach). In such cases, with the agreement of relatives, subsequent disposal may be the preferred option. Version No.2.0 October 2014 Page 12 of 25 Management of Viral Haemorrhagic Fevers 4.9 COMMUNICATION CASCADE Any possible, highly possible or confirmed case of VHF must be notified to the Consultant in Public Health Medicine (CPHM) without delay. The On- Call CPHM will issue a communication cascade to relevant clinical and management colleagues about a possible diagnosis of VHF. If transfer of the patient is likely, early communication with Scottish Ambulance Service is required. Following notification, a teleconference will be arranged to discuss the risk assessment and clinical requirements for transfer. Specialty Infectious Diseases Consultant Location Monklands General Hospital Telephone number 01236 748 748 Consultant Public Health Medicine (Health Protection) Kirklands (during working hours) 01698 858 232 On Call Consultant Public Health Medicine Consultant Microbiologist Via switchboard Monklands General Hospital Monklands General Hospital 01236 748 748 Wishaw General Hospital 01698 361 100 Hairmyres General Hospital 01355 585 000 Imported Fever Service 0844 7788 990 Duty Consultant Rare and Imported Pathogens Laboratory (if above number not available) West of Scotland Control Centre (ask for duty manager) 01980 612100 (24hr) Health Protection England (previously HPA) Scottish Ambulance Service 01236 748 748 03333 990125 (24 hrs) 0345 123999 (24 hrs) High Level Isolation unit (HLIU) Air Ambulance Royal Free Hospital , London 0844 8480700 (local rate from outside London) OR: 020 7794 0500 Switchboard – 24 hrs ask for ID Consultant on call NHS Lanarkshire Procurement Hairmyres Hospital IPCT Contact Number (s) Kirklands Hospital Version No.2.0 October 2014 01355 584956 (during working hours) 01698 858254 (during working hours) Page 13 of 25 Management of Viral Haemorrhagic Fevers 4.10 PUBLIC HEALTH MANAGEMENT On notification of any potential case of VHF, the duty Consultant in Public Health Medicine will convene and chair an Incident Management team (IMT). The CPHM or Director of Public Health must notify HPS and the Chief Medical Officer’s team in the Scottish Government. Using the Hospital Infection incident Assessment Tool (HIIAT) potential cases should be categorised as: Low possibility of VHF- AMBER High possibility of VHF (with or without bleeding etc) –RED Confirmed case of VHF - RED The ‘Management of Public Health Incidents Plan’ will be activated. Core membership of the IMT will include: CPHM Health Protection Nurse Consultant in Infectious Diseases Consultant Microbiologist/Infection Control Doctor Scottish Ambulance Service Infection Control Nurse Consultant in Occupational Health Medicine Administrative support Communications officer Other persons may be co-opted at the discretion of the IMT. Members of the IMT will be responsible for briefing other members of their organisation as appropriate. Key actions of the IMT: Identify, assess and categorise contacts Arrange advice and reassurance to contacts Ensure appropriate monitoring of higher risk contacts Arrange further evaluation of contacts who develop symptoms To consider antiviral prophylaxis, and arrange as necessary Review patient management including provision of post recovery advice Review control measures Prepare advice for general public Prepare briefing for professionals including Scottish Government Version No.2.0 October 2014 Page 14 of 25 Management of Viral Haemorrhagic Fevers 4.10.1 Management of Staff accidentally exposed to potentially infectious material Any staff member who is exposed to, or sustains an injury with potential for exposure to, blood or body fluids in cases of highly possible or confirmed cases of VHF must: Take immediate first aid in line with current policy (e.g. needlestick injury) Wash the affected area soap and running water Irrigate mucous membranes with emergency wash bottles All such exposures must be reported without delay to the Consultant in Infectious Diseases, Infection Control Doctor and SALUS Occupational Health & Safety. A DATIX form should be completed as per policy for any blood or body fluid exposure incident. If VHF is subsequently confirmed in the source patient, the incident must be reported under Reporting of Injuries, Diseases, and Dangerous Occurrences Regulations 2013 (RIDDOR). The exposed individual must be followed up as a High Risk contact (Category 3) see Appendix 4. 5. ROLES AND RESPONSIBILITIES All staff are responsible for implementing and following the information provided in this policy. 6. RESOURCE IMPLICATIONS There are implications for additional cost associated with: Additional PPE Laboratory costs (including staffing) Transport costs (cost of transporting Category 4 samples to specialist laboratory, internal transfer NHS Lanarkshire, external transfer to HLIU and) Waste disposal costs (incineration) Additional consumables 7. COMMUNICATION PLAN This policy is available on NHS Lanarkshire intranet. Changes to policy or guidance will be communicated to key personnel via: Email Discussion at departmental meetings Note on staff briefing on First Port Educational sessions 8. QUALITY IMPROVEMENT Compliance with this policy will be monitored by the Infection Control Team. Version No.2.0 October 2014 Page 15 of 25 Management of Viral Haemorrhagic Fevers 9. EQUALITY & DIVERSITY ASSESSMENT √ This policy meets NHS Lanarkshire’s EDIA (tick box) 10. Summary or Frequently Asked Questions (FAQs) If you have any questions about this policy or how to implement it, please contact the Infection Control team/Health Protection Team to discuss your query. A separate FAQ sheet is available on the Health Protection Scotland site: http://www.documents.hps.scot.nhs.uk/travel/vhf/ebola-QA-october-2014.pdf 11. REFERENCES Department of Health (2014) Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious disease of high consequence(Sept 2014) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/354640/VHF _guidance_document_updated_links.pdf HPS (2014) Advice for Purchase of Required PPE for Viral Haemorrhagic Fever (VHF) preparedness http://www.documents.hps.scot.nhs.uk/travel/vhf/vhf-ppe-purchasing-v2.0.pdf HPS (2014) Viral Haemorrhagic Fever – Precautions Summary RCPath(2014) Autopsy in patients with confirmed or suspected Ebola virus http://www.rcpath.org/Resources/RCPath/Migrated%20Resources/Documents/P/PUBS_E bolaAutopsy_Sept14_V2.pdf Scottish Ambulance Service (2014) -HS003t – Hazard Group 4 Viral Haemorrhagic Fevers & Similar Infectious Diseases of High Consequence http://www.documents.hps.scot.nhs.uk/travel/vhf/vhf-transportation-patient-v1.2.pdf HPS(2014) VHF information pages http://www.hps.scot.nhs.uk/travel/viralhaemorrhagicfever.aspx World Health Organisation (2014) Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in HealthCare Settings, with Focus on Ebola http://apps.who.int/iris/bitstream/10665/130596/1/WHO_HIS_SDS_2014.4_eng.pdf?ua=1& ua=1&ua=1 Version No.2.0 October 2014 Page 16 of 25 Management of Viral Haemorrhagic Fevers Appendix 1 – VHF decision making algorithm (Sept 2014) Version No.2.0 October 2014 Page 17 of 25 Management of Viral Haemorrhagic Fevers Appendix 2: Patient Pathway GP or Out of hours staff identify possible VHF case A&E or Receiving Unit staff identify possible VHF case Patient with: Fever or history of fever Travel in past 3 weeks to o Guinea, o Liberia, o Nigeria. o Congo DR, o Sierra Leone Or any other location where outbreak reported Patient with: Fever Cared for/contact with blood or body fluid of known or suspected VHF case (human or animal) Lived or worked in basic rural conditions? Visited caves/mines? Contact with primates/antelopes/bats? Sustained a tick bite? Close involvement in animal slaughter? Isolate patient – limit further staff contact GP/Hospital clinician to compile list of contacts YES Patient is at GP practice/in hospital? NO GP/Hospital clinician to notify on-call ID Consultant & duty CPHM VHF still actively considered? YES ID Consultant liaise with SAS to arrange patient transport & admission to MGH ward 2 (Patient must not use public transport) NO Patient with: Fever Travel in past 3 weeks to a VHF endemic country Version No.2.0 October 2014 Provide contact list to CPHM/ ID Consultant ID Consultant to provide GP with advice on patient management as per standard referral pathway for managing febrile travellers – malaria needs to be excluded Page 18 of 25 Arrange admission to hospital if clinically indicated- standard referral pathway Arrange urgent Malaria Screen Management of Viral Haemorrhagic Fevers Appendix 3: Infection Control Precautions – VHF (adapted from HPS precautions summary Sept 2014) Control Measure Patient placement (Accommodation) Low possibility case Isolate immediately in single room with en-suite or dedicated commode High Possibility case or Highly Possibility case (bleeding/bruising and/or profuse vomiting or diarrhoea present) Isolate immediately in single room (Negative pressure and ante room where possible) with en-suite or dedicated commode OR AND ID Consultant to arrange transfer to ID unit Monklands General hospital if clinically appropriate ID Consultant to arrange transfer to ID unit Monklands General hospital if clinically appropriate Confirmed VHF case Isolate immediately in negative pressure isolation room with ante-room and ensuite or dedicated commode AND OR ID Consultant to arrange urgent transfer to HLIU at Royal Free Hospital, London if clinically appropriate ID Consultant to arrange urgent transfer to High Level Isolation Unit (HLIU) –Royal Free Hospital, London if clinically appropriate Staffing/contact with people If patient presenting at GP practice or A&E, limit contact with other people Clinical staff only (no domestics etc) Keep up to date list of staff who enter the room for possible contact assessment. Clinical staff only Keep up to date list of staff who enter the room for contact assessment Clinical staff to perform routine cleaning Clinical staff to perform routine cleaning Moving patient between wards and departments Version No.2.0 As per standard hospital procedures October 2014 Do not transfer unless under direct supervision of ID Consultant/IPCT Page 19 of 25 Control Measure PPE Management of Viral Haemorrhagic Fevers Low possibility case High Possibility case or Highly Possibility case (bleeding/bruising and/or profuse vomiting or diarrhoea present) For all contact: PPE must cover all exposed skin with sufficient integrity to prevent ingress or seepage of liquids or airborne particles Disposable surgical apron (Green) For all contact: Disposable clinical gloves Fluid repellent gown with theatre scrubs under Standard footwear (as per Disposable surgical (green) apron dress code) If risk of splashing, add: FFP3 mask Disposable full face visor Disposable full face visor or goggles OR Disposable fluid shield Double gauntlet type gloves (glove to overlap wrist cuff) visor mask Over boots / Wellington Boots if possible exposure to high Cape hood (where volume of body fluids necessary) Cape Hood If vomiting/bleeding/bruising present – adopt PPE as for high possibility case until VHF screen negative Confirmed VHF case PPE must cover all exposed skin with sufficient integrity to prevent ingress or seepage of liquids or airborne particles For all contact: Fluid repellent gown with theatre scrubs under Disposable surgical (green) apron FFP3 mask Disposable full face visor or goggles Double gauntlet type gloves (glove to overlap wrist cuff) Cape Hood Wellington boots Avoid Aerosol Generating Procedures (AGPs) unless clinically necessary. For AGPs: Only staff who have passed the face fit test should be allowed to enter into an area where an FFP3 mask is required and must use the particular make and model of mask for which they have been fit tested for. Version No.2.0 October 2014 Page 20 of 25 Control Measure Hand hygiene Management of Viral Haemorrhagic Fevers Low possibility case High Possibility case or Highly Possibility case (bleeding/bruising and/or profuse vomiting or diarrhoea present) Hand hygiene before donning gloves. Confirmed VHF case Hand washing with soap and water after removing PPE Waste Treat ALL waste as clinical – dispose of into ORANGE bags (Category B waste) Sharps waste – YELLOW box & YELLOW lid³ All waste for incineration – Double YELLOW bags³ (Category A waste) All waste for incineration – Double YELLOW bags³ Sharps waste – YELLOW box & YELLOW lid³ Sharps waste – YELLOW box & YELLOW lid³ Hold in safe area until special uplift for incineration/autoclave Hold in safe area until special uplift for incineration/autoclave Linen Reusable linen- treat any linen visibly contaminated with blood or body fluids as disposable (high risk- YELLOW waste bag). All reusable linen must be disposed of into YELLOW waste bags³ Disposable linen could be considered If no visible contamination, use red bag as per SCIPs Equipment *Do not store supplies inside room* *Do not remove any equipment from the patient room without permission of the ICT* Single use equipment(including BP cuffs, stethoscopes, thermometers, washbowls) Needle free IV systems Disposable crockery & cutlery – dispose of into YELLOW waste³ Dedicated commode – use disposable liner. Solidify all content using granules. Dispose of content into double YELLOW disposable waste bags³ (DO NOT MACERATE CONTENT) Version No.2.0 October 2014 Page 21 of 25 Control Measure Cleaning & decontamination Management of Viral Haemorrhagic Fevers Low possibility case High Possibility case or Highly Possibility case (bleeding/bruising and/or profuse vomiting or diarrhoea present) Toilet/commode: clean with 10,000ppm av. Chlorine after each use Confirmed VHF case Decontamination of room & equipment: use disposable equipment where possible. Clean all surfaces with 1,000ppm av. Chlorine at least daily Terminal cleaning: clean with 1,000ppm av. Chlorine. If VHF confirmed, room fumigation required on discharge or death. Leave decontaminated equipment in room until fumigation process complete. Mattress: clean and check as per local policy. If VHF confirmed, dispose of as waste for incineration. Blood & body fluid spillage *All spills of blood/body fluid in ANY patient being assessed or treated for VHF should be treated as high risk for VHF*. Use full PPE as for high risk of VHF (fluid repellent gown, wellington boots, face/eye protection) Blood: 10,000ppm av Chlorine for 3 minutes Urine: solidify content, dispose of as Category A waste (Yellow bag) – apply 10,000ppm av. Chlorine for 3 mins Refer to SICPS Appendix 11 for further info. Management of occupational exposure Follow SICPS - take immediate steps for First Aid Follow SICPS – take immediate steps for First Aid. Report and refer urgently to Clinical Microbiologist, ID Consultant and SALUS. Provide reassurance & confirm when stand down that exposure was not to VHF Provide reassurance & confirm when stand down that exposure was not to VHF OR If VHF confirmed in source patient – Manager must report as a RIDDOR event. Full support for staff member & family throughout incubation period Ongoing assessment Monitor for bleeding, bruising, diarrhoea and/or vomiting If symptoms appear – treat as high possibility of VHF until VHF screen negative If Malaria negative AND pyrexial AND no other diagnosis– discuss with ID Consultant /HLIU staff Version No.2.0 October 2014 Page 22 of 25 Control Measure Stand down (discontinue precautions) Version No.2.0 Management of Viral Haemorrhagic Fevers Low possibility case High Possibility case or Highly Possibility case (bleeding/bruising and/or profuse vomiting or diarrhoea present) When ID Consultant confirms: VHF negative Responding to treatment (alternate diagnosis) Apyrexial for 24hours October 2014 Page 23 of 25 Confirmed VHF case On patient discharge or death. Management of Viral Haemorrhagic Fevers Appendix 4 – Categorisation and Management of Contacts Risk Category Description Action & Advice No direct contact with the patient or body Reassure about absence of risk No risk (Category 1) Low risk (Category 2) Casual contact e.g. sharing a room with the patient, without direct contact with body fluids or other potentially infectious material Direct contact with the patient, e.g. routine medical/nursing care, handling of clinical/laboratory specimens, but did not handle body fluids, and wore personal protective equipment appropriately. Reassure about low risk Passive monitoring Self-monitor for fever and other disease compatible symptoms for 21 days from last possible exposure Report to the HPN if temperature >38.0ºC, with further evaluation as necessary High risk Unprotected exposure of skin or mucous membranes to potentially infectious blood or body fluids, including on clothing and bedding. (Category 3) This includes: unprotected handling of clinical/laboratory specimens mucosal exposure to splashes needlestick injury kissing and/or sexual contact. Version No.2.0 October 2014 Inform about risks Active monitoring Record own temperature daily for 21 days following last contact with the patient and report this temperature to the Monitoring Officer by 12 noon each day, with further evaluation as necessary. Inform Monitoring Officer urgently if symptoms develop. Page 24 of 25 Management of Viral Haemorrhagic Fevers Appendix 5: WHO (2014) Correct Method of putting on and removing PPE Version No.2.0 October 2014 Page 25 of 25
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