Interim Western Australia Viral Haemorrhagic Fever Response Plan 26 October 2014 health.wa.gov.au Contents About this document 2 1. 3 2. 3. Introduction 1.1. Background 3 1.2. Legislative basis 4 1.3. Quarantine hospitals 4 1.4. Other hospitals 5 Overview of Viral Haemorrhagic Fevers 6 2.1. Incubation periods 6 2.2. Clinical features of cases of VHF 6 2.3. Specific treatments for VHF patients 7 2.4. Transmission 7 Initial assessment and management of a possible VHF case 9 Appendix 1 - Assessment and management of suspected cases of Ebolavirus disease in Emergency Departments 12 Appendix 2 - EVD risk assessment checklist 13 Appendix 3 - National case definitions of Ebolavirus disease 16 Appendix 4 - Public Health response and Public Health Unit responsibilities 18 Appendix 5 - Infection prevention and control guidelines for Ebolavirus disease (non-quarantine hospitals) 20 Appendix 6 - Healthcare worker education and training resources for Ebolavirus disease 25 Appendix 7 - Donning and doffing PPE procedures checklist 26 Appendix 8 - Cleaning and disinfection 27 Appendix 9 - Waste treatment and disposal 30 Appendix 10 - Post-mortem care and examination 33 Appendix 11 - EVD patient transfer and transport guidelines 37 Appendix 13 - Ebolavirus disease fact sheet 40 Appendix 14 - Fact sheet for contacts of a person with Ebolavirus disease 43 Appendix 16 - Contact numbers 44 Appendix 17 - Specimen collection and handling 46 Appendix 18 - WA EVD laboratory testing guidelines 46 Appendix 19 - Ebolavirus Disease Case Report Form 47 1 About this document The Interim Western Australia Viral Haemorrhagic Fever Response Plan replaces the 2007 Contingency Plan for the Public Health Management of Viral Haemorrhagic Fever Within Western Australia. It is an extensive revision and has been prompted by the large outbreak of Ebolavirus disease (EVD) in West Africa. The focus, therefore, is on EVD and much of the information in the appendices is specific for EVD. However, the principles of managing other types of VHF are very similar and this document could equally be used to provide management guidance for those diseases. The word „Interim‟ is included in the title because the information within the document is likely to change frequently owing to the rapidly changing nature of the 2014 EVD outbreak, and also to reflect the fact that guidance on all facets of the response is not yet included. This information will, over time, be added to the appendices, the titles of which are already included. The main text of the document is unlikely to change significantly. 2 1. Introduction 1.1. Background This document provides the framework to guide the response to suspected and confirmed cases of VHFs in WA, and should assist each hospital in producing a site-specific response plan. Viral haemorrhagic fevers (VHFs) covered by this plan (Ebolavirus disease, Marburg virus disease, Lassa fever and Crimean-Congo haemorrhagic fever) are a group of infectious diseases that cause serious illness in humans, with high case fatality rates and the potential for person-to-person transmission, including in healthcare settings. These viruses are endemic in specific geographic regions - primarily in Africa, but also including the Middle East, Eastern Europe and Asia. Other haemorrhagic fevers that are not characterised by person-to-person spread, such as yellow fever, severe dengue infections, hantaviruses and South American arenavirus infections, are not covered by this document. VHFs do not occur in Australia and establishment here is unlikely as environmental conditions do not support the natural reservoirs and vectors of these viruses. The possibility of a VHF case being diagnosed in Western Australia (WA) is very low, and relates primarily to travellers from endemic areas, particularly from Africa. However, the risk may be increased in certain circumstances, such as during periodic epidemics of Ebolavirus disease (EVD) that have occurred in central Africa since 1976. The large outbreak of EVD in several West African countries in 2014, including spread to populous urban areas, has posed the most significant risk of spread to Australia and other developed countries, more so by returning humanitarian workers than by returning tourists or citizens of these countries travelling to Australia. To date, the only documented case of significant VHF diagnosed in Australia was a convalescent case of Lassa fever diagnosed in a rural hospital in NSW in 1985. Other suspect cases investigated previously have eventually been diagnosed as other febrile illnesses, including malaria, leptospirosis or Human Immunodeficiency Virus seroconversion illness. Contingency planning for VHFs aims to enable early identification of suspect cases; appropriate assessment, laboratory testing and clinical management in a safe environment; and prevention of transmission. 3 Diagnosis and management of VHFs in WA presents several challenges: the rarity of patients presenting with VHFs in Australia heightens the risk of misdiagnosis the early clinical presentation (e.g. fever, headache, pharyngitis, myalgia) is non-specific and mimics more common and less severe conditions the risk for transmission to contacts, including healthcare workers (HCWs), particularly during the early symptomatic phase prior to the diagnosis being considered and appropriate infection prevention and control precautions implemented while evidence and international guidelines indicate that suspected, probable and confirmed cases should be isolated in a single room with use of standard and transmission-based (contact and droplet) infection prevention and control precautions, the high level of consequences if transmission of VHFs such as EVD occurs, means that more stringent precautions to prevent aerosol transmission are likely to be used in Australian healthcare settings, where this is possible. This is also reflected in guidelines for handling of specimens in laboratories. 1.2. Legislative basis VHFs are classified as “dangerous infectious diseases” for purposes of notification and public health management in WA (Health Act 1911). This allows the use of additional powers, as defined in section 251 of the Act, to facilitate public health management of cases and contacts, such as orders requiring isolation, quarantine, testing and disinfection, should this be appropriate. VHFs are also nationally notifiable and are prescribed quarantinable diseases under the Commonwealth Quarantine Act 1908, which in effect means that responsibility for surveillance, cost of treatment and control of these diseases lies with the Commonwealth Department of Health. In practice, however, Commonwealth responsibility is limited to national coordination and activities at international borders, and the WA Department of Health (WA Health) accepts delegated responsibility for clinical and public health management of these diseases, with the Director of the Department‟s Communicable Disease Control Directorate being appointed the Chief Human Quarantine Officer for the state, under Commonwealth legislation. Other WA Health medical officers are similarly appointed as Human Quarantine Officers (see Appendix 15). Costs incurred in treating a patient with a suspected quarantinable disease are, at least in theory, recoverable from the Commonwealth. 1.3. Quarantine hospitals In WA, Sir Charles Gairdner Hospital (SCGH) is the designated hospital for the treatment of adults (including pregnant women) with quarantinable diseases, including VHFs. Princess Margaret Hospital (PMH) is designated for treatment of children. These hospitals have purpose-built isolation rooms, 4 including in their intensive care units, for the containment of patients with VHFs and other high-risk pathogens, in order to minimise the risk of transmission to HCWs, other patients and visitors. PathWest at the QE II Medical Centre campus, adjacent to SCGH, maintains an accredited physical containment level 3 (PC3) laboratory with capacity to undertake a range of microbiological and other diagnostic testing on blood and other specimens from patients being investigated for VHFs. 1.4. Other hospitals All hospitals must consider that a person in whom a diagnosis of a VHF needs to be ruled out, or even a real case, could self-present or be referred to an emergency department by a general practitioner. Such cases will need to be assessed, managed and in some situations admitted, prior to it being feasible to arrange transfer to either of the designated quarantine hospitals. Each hospital, including those in country regions, should therefore have in place a response plan for the assessment, treatment and referral of patients with suspected VHFs. Plans should include provision for: an isolation care area with an adjoining ante-room or an adjacent unoccupied room, with private bathroom facilities, to manage patients until they can be transferred, while recognising that the labile nature of VHF infections may make timely transfer difficult appropriate personal protective equipment (PPE) for HCWs managing VHF cases, according to Appendix 5 the provision of education to HCWs on necessary infection prevention and control measures and on the use of appropriate PPE arrangements for transfer of patients to SCGH or PMH (for paediatric patients) as soon as clinically practicable. 5 2. Overview of Viral Haemorrhagic Fevers 2.1. Incubation periods Incubation periods for these diseases are: i Lassa fever 6 – 21 days ii Ebolavirus disease 2 – 21 days iii Marburg virus disease 3 – 10 days iv Crimean-Congo haemorrhagic fever 1 – 12 days 2.2. Clinical features of cases of VHF These infections have variable and non-specific clinical manifestations. As an example, Lassa Fever is thought to have an overall mortality rate of 5% but this rises to 15-20% in hospitalised patients. Mortality rates in outbreaks of EVD in Africa have ranged from 50-90%, with variability probably related to different levels of care available, and perhaps to virulence characteristics of different strains of the virus. Epidemics and small clusters of VHFs due to nosocomial transmission among hospitalised patients and staff have been reported, primarily associated with EVD in Africa. In the early phase of these diseases when non-specific influenza-like symptoms predominate, the risk of transmission is thought to be low, but in those who progress to haemorrhage, collapse and organ failure, their body fluids are highly infectious. Ebola and Marburg virus disease: Characterised by the sudden onset of fever, malaise, myalgia, and headache, followed by pharyngitis, vomiting, diarrhoea, and a maculo-papular rash. Haemorrhagic manifestations are seen in less than half of cases. Haemorrhage and shock are more likely in the second week. Lassa fever: Characterised by the gradual onset of fever, malaise, myalgia, headache, vomiting and diarrhoea. Pharyngitis and conjunctivitis are prominent. Only 20 per cent have severe symptoms, which may include pleural effusions, haemorrhage, seizures, encephalopathy and oedema of the face and neck. Crimean-Congo haemorrhagic fever: Characterised by the sudden onset of fever with headache, myalgia, arthralgia, abdominal pain, and vomiting. Conjunctivitis, pharyngitis and palatal petechiae are also common. Bruising and widespread haemorrhage typically starts after four days. 6 2.3. Specific treatments for VHF patients Administration of the anti-viral drug ribavirin may be appropriate in some cases, on the recommendation of an infectious disease physician. A stock of ribavirin is maintained for this purpose in the Pharmacy Department at SCGH. Experimental treatments, albeit in very limited supply, may have contributed to recovery in some HCWs infected with Ebolavirus during the 2014 West African epidemic. 2.4. Transmission Following initial human infection from an animal source, transmission of VHFs is usually from person-toperson by contact with contaminated body fluids, either directly or via fomites. However, transmission by airborne droplets has not been discounted in some cases. However, the severity and consequences of infection require that a more elaborate and strict level of containment be consistently maintained for the prevention of nosocomial transmission, both at the bedside and in the diagnostic laboratory. At the time of writing this plan, transmission of EVD to HCWs in western countries had occurred on three occasions (two from one index case and one from another), during the 2014 outbreak. The reasons for these transmissions is purported to be a breach in protocols for the use of PPE. 7 Table 1 - Summary of the major characteristics of the viral haemorrhagic fevers 8 3. Initial assessment and management of a possible VHF case This section concerns assessment and management of a person in whom VHF is suspected in an emergency department (ED) of a hospital other than designated quarantine hospitals (Sir Charles Gardiner Hospital (SCGH) for adults; or Princess Margaret Hospital (PMH) for child cases). The designated quarantine hospitals have their own VHF plans that include management of suspected and confirmed cases in their EDs, wards and intensive care units. The following actions should be taken by a medical practitioner/ health professional who suspects VHF on the basis of a patient‟s symptoms (fever, or symptoms of fever, with or without additional symptoms such as headache, myalgia, arthralgia, vomiting, diarrhoea, abdominal pain or unexplained bleeding/bruising in past 24 hours) and travel history (travel to a country where there is an outbreak of a VHF, or contact with a person with a VHF, or the blood or body fluids of a person with a VHF within the incubation period of the VHF (up to 21 days)): immediately isolate the patient in a negative pressure isolation room (NPIR) (or single room if NPIR not available) and minimise unnecessary staff and family contact. Do not allow the patient to leave the health service ensure appropriate infection prevention and control precautions are taken by all staff (and by parent(s) of a child case if it is essential for them to remain with the patient) who are providing care in the same room (See Appendix 5) where available within a health facility, notify the Infection Prevention and Control Practitioner obtain clinical and exposure information to allow an appropriate initial risk assessment to be made (an example is shown in Appendix 2 EVD Risk Assessment Checklist) notify the on-call public health physician at the Communicable Disease Control Directorate (CDCD) on (08) 9388 4801(during office hours) or (08) 9328 0553 (after-hours paging system) a final risk assessment will be undertaken between the practitioner, the CDCD on-call public health physician and the on-call microbiologist from the designated quarantine hospital, and further management advised depending on the risk assessment, the patient may remain in isolation in the ED they presented to and have samples taken for urgent testing for VHF at PathWest QE II Laboratory (if deemed low risk), or may be transferred immediately to the designated quarantine hospital (if deemed higher risk) 9 avoid taking a throat swab or undertaking any aerosol generating procedure or venepuncture unless immediately essential for clinical care (see Appendix 18 WA EVD laboratory testing guidelines [currently under development]) avoid calling St John Ambulance or the Royal Flying Doctor Service or organising any transport to another health service unless advised by on-call CDCD public health physician, or is immediately essential for life-saving care. Transfer will be organised by CDCD and SCGH/PMH in accordance with Appendix11 EVD Patient transfer and transport guidelines if advised by the on-call CDCD public health physician, compile a list of patients and staff who were in contact with the patient, including their mobile phone numbers and other contact information if a patient is shown to have a VHF and has been transferred to a designated quarantine hospital, environmental cleaning, disinfection and waste management should be carried out as detailed Appendix 8 Cleaning and disinfection and Appendix 9 Waste treatment and disposal. take any other actions advised by the on-call CDCD public health physician relating to risk management or risk communication to staff and patients. 10 The remainder of this document applies specifically to Ebolavirus Disease (EVD). Sections for other VHFs will be added at a later date. The appendices will be populated further as policies and procedures are developed 11 Appendix 1 - Assessment and management of suspected cases of Ebolavirus disease in Emergency Departments Does the patient report: (i) A documented FEVER, or symptoms of fever (sweats, chills, rigors or night sweats), with or without ADDITIONAL SYMPTOMS such as headache, myalgia, arthralgia, vomiting, diarrhoea, abdominal pain or unexplained bleeding/bruising in past 24 hours. (ii) TRAVEL within a country where there is currently an EVD outbreak* in the 21 days prior to illness onset. YES NO ‘PATIENT UNDER INVESTIGATION‟ Alert Senior Medical Officer and Senior Nurse. Triage nurse to don PPE and ensure droplet and contact precautions. Give surgical mask patient to patient, ask them not to touch anything and escort (preferably walking) to single room via a predefined route. Staff member to walk 2m ahead to clear path of others Provide a vomit bag if vomiting. NOT EVD: Standard precautions and normal medical evaluation Senior ED Medical Officer to undertake INITIAL RISK ASSESSMENT (use Appendix 2 – EVD risk assessment checklist in Interim Western Australia Viral Haemorrhagic Fever Response Plan) Call the on-call public health physician from the CDCD (08 9388 4801(BH); 08 9328 0553 (A/H)) who will undertake FINAL RISK ASSESSMENT in liaison with the on-call microbiologist from the designated quarantine hospital ‘SUSPECTED CASE‟ Suspected case deemed LOW RISK of having EVD NOT A „SUSPECTED CASE‟ Standard precautions and normal medical evaluation *EVD OUTBREAK COUNTRY LIST EVD outbreaks at 24/10/2014 Guinea Liberia Sierra Leone Democratic Republic of the Congo. Check WHO for recent updates: www.who.int/csr/don/en/ Suspected case deemed HIGHER RISK of having EVD infection Take samples for Ebolavirus as per PathWest QEII sampling kit, if available, or on advice of on-call microbiologist from designated quarantine hospital Patient to remain in ED in isolation until results known Arrange immediate transfer to designated quarantine hospital (SCGH-adults; PMH – children) WA Health Interim Western Australia Viral Haemorrhagic Fever Response Plan 26 October 2014 PPE for ‘Suspected cases’: Standard plus contact, droplet and additional respiratory precautions (‘no skin exposure’ approach) Hand Hygiene Double glove Long sleeved, cuffed, fluid repellent gown (inner and outer) Disposable full face visor Fluid repellent N95 or P2 mask/respirator Fluid resistant hood to protect head and neck Overshoes and leg coverings. Fluid repellent N95 or P2 mask/respirator Use a P2+ respirator and non vented goggles for AGP. Impermeable boots (where available, higher level PPE ensembles (Jupiter hoods and powered air purifying respirators (PAPRs)) can be used for patients who have diarrhoea or vomiting) Other considerations for ‘suspected cases’ Maintain log of all persons entering patient's room. Limit use of needles and other sharps. Limit phlebotomy and laboratory testing to those procedures essential for diagnosis and medical care Avoid aerosol generating procedures (AGP) Restrict entry to room to necessary staff. Alert your infection control team and ID Physician 12 Appendix 2 – EVD risk assessment checklist Patient’s name: ....................................................... DOB:......................... UMRN:........................... Clinician:.................................................................. Date:........................ Time:.............................. EBOLA VIRUS DISEASE RISK ASSESSMENT – HISTORY CHECK LIST • Examining HCW: standard plus contact, droplet and additional respiratory precautions. • Assistant HCW: >2m away from patient at all times, documents history and examination findings and does not examine the patient. HISTORY: 1. Reason for attending hospital. Felt unwell Concerned about possible exposure to someone with Ebola Virus Disease (EVD) Accompanied another patient:................................ ............................................. SYMPTOMS: 2. Patient’s symptoms and signs. Fever Abdominal pain(details): - onset: - timings: Diarrhoea* Told to attend ED by: Public Health Unit/CDCD GP Other:................................ blood Lethargy Myalgia Arthralgia Nausea Anorexia Sore throat SOB Cough* Sneezing* Hiccups Unexplained bruising (locations): Bleeding* - nose - eyes - vaginal - urine - sputum Chest pain: Other: Vomiting* blood Headache (details): Rash(locations): * secretory symptoms 3. Past medical history: 4. Medications: 5. Allergies: 6. Occupation: 7. Other family members who are unwell: RISK OF EXPOSURE TO EVD 13 8. Travel in last 21 days. To EVD affected country: Liberia Sierra Leone Guinea Democratic Republic of Congo Other:........................................ Dates: Cities/towns visited: Accommodation: Hotel (details e.g. 5 star)........................................ Stayed with family/friends Other: .................................................................... Villages/rural regions visited: Reason for visit: 9. High risk activities in Ebola affected country. Has worked/visited a hospital, clinic, laboratory or other health care setting. Details (e.g. location, presence of EVD patients) Any: Needle stick injury from an EVD patient. Mucous membrane exposed to blood or body fluids from an EVD patient. Direct skin contact with skin, blood or body fluids from an EVD patient. Processed blood or body fluids from an EVD patient without appropriate PPE. Direct contact with a dead body in an Ebola-affected area without appropriate PPE. Has spent time in care areas of EVD patients without appropriate PPE. Has had contact with a sick person in the community. Type of contact Close contact, cared for Brief direct contact e.g. patient. shaking hands Unknown diagnosis Suspected EVD Confirmed EVD Diagnosis other than EVD PPE used Yes, all of Occasionally time. or not at all. Other activities: Attended a funeral (details e.g. contact with dead) Consumption of bush meat LIKELIHOOD OF ALTERNATIVE PATHOLOGY 10. Protective/risk factors for other diseases. Mosquito bites Consumption of unsafe water Taken malaria prophylaxis Consumption of spoiled food Patient’s name: ....................................................... Contact with wild animals (e.g. bats) Tick bite DOB:......................... UMRN:........................... 14 Clinician:................................................................... Date:.......................... Time:............................ EBOLA VIRUS DISEASE RISK ASSESSMENT – PHYSICAL EXAMINATION • Examining HCW: standard plus contact, droplet and additional respiratory precautions. • Assistant HCW: >2m away from patient at all times, documents history and examination findings and does not examine the patient. INITIAL A: B: C: RR TEMPERATURE: GCS: E SpO2 M V PR BP Pupils: IF THE ABOVE ARE ALL NORMAL AND PATIENT IS COMFORTABLE CONSIDER CALLING CDCD AT THIS POINT. Abdominal: Cardio-respiratory: Orifices: any bleeding? DO NOT USE A STETHOSCOPE Skin: any rash or bruising? Neurological: Avoid aerosol generating procedures e.g. examination of throat. 15 Appendix 3 - National case definitions of Ebolavirus disease CNDA National guidelines for Ebolavirus disease (EVD) http://www.health.gov.au/ebola classifies patients into the following categories : Person under investigation Requires clinical evidence and limited epidemiological evidence. Clinical evidence requires fever >38o. Additional symptoms such as unexplained haemorrhage or bruising, muscle pain, marked vomiting, marked diarrhoea, should also be considered Limited epidemiological evidence requires only travel to an EVD-affected area. Suspected case Requires clinical evidence and epidemiological evidence. Clinical evidence – as above Epidemiological evidence requires a low risk or high risk exposure as defined below. Lower risk exposures: Household contact with an EVD case (in some circumstances this might be classified as higher risk such as where the household was in a resource-poor setting) Being within approximately 1 metre of an EVD patient or within the patient‟s room or care area for a prolonged period of time (e.g., healthcare workers, household members) while not wearing recommended personal protective equipment (PPE) Having direct brief contact (e.g., shaki8ng hands) with an EVD patient while not wearing recommended PPE Higher risk exposures: Percutaneous (e.g. needle stick) or mucous membrane exposure to blood or body fluids of an EVD patient (either suspected or confirmed) Direct skin contact with blood or body fluids of an EVD patient without appropriate personal protective equipment (PPE), Laboratory processing of body fluids of suspected, probable, or confirmed EVD cases without appropriate PPE or standard biosafety precautions, or Direct contact with a dead body without appropriate PPE in a country where an EVD outbreak is occurring, or Direct handling of sick or dead animals from disease-endemic areas consumption of “bushmeat” in a country where EVD is known to occur. 16 Probable case Requires clinical evidence and epidemiological evidence, AND, laboratory suggestive evidence of EVD. Clinical evidence – as above Laboratory suggestive evidence includes: Isolation of virus pending confirmation by CDC, Atlanta or NIV, Johannesburg; OR; Detection of specific virus by nucleic acid testing, antigen detection assay, or electron microscopy pending confirmation by CDC, Atlanta, or NIV, Johannesburg; OR IgG seroconversion or a significant increase in antibody level or a fourfold or greater rise in titre to specific virus pending confirmation by CDC, Atlanta, or NIV, Johannesburg; OR Detection of IgM to a specific virus pending confirmation by CDC, Atlanta, or NIV, Johannesburg. Confirmed case Requires laboratory definitive evidence only. Laboratory definitive evidence requires confirmation of EVD infection by the Special Pathogens Laboratory, CDC, Atlanta, or the Special Pathogens Laboratory, National Institute of Virology (NIV), Johannesburg. Isolation of a specific virus; OR Detection of specific virus by nucleic acid testing or antigen detection assay; OR IgG seroconversion or a significant increase in antibody level or a fourfold or greater rise in titre to specific virus. Note: If a risk assessment determines that a person under investigation should be tested for Ebolavirus, the person should be managed as a suspected case from that point forward regardless of clinical and epidemiological evidence. 17 Appendix 4 – Public Health response and Public Health Unit responsibilities WA Health will undertake the following actions in accordance with the CDNA national guidelines for public health management of EVD as part of the public health response to a suspected or confirmed case of EVD: undertake an assessment of a potential suspected case advise on public health aspects of case management, including making an EVD factsheet available (Appendix 13 Ebolavirus disease fact sheet, and Appendix 14 Fact sheet for contacts of a person with Ebolavirus disease) undertake all contact tracing and contact management, including categorisation of risk, determining control measures required (such as exclusion of contacts from a workplace) and undertaking active surveillance if required provide relevant directions, advice and alerts to the public. WA Health will assess the nature of the exposures of any contacts of a suspected or confirmed case of EVD. The approaches likely to be taken for categories of contacts are described below. Follow-up for people with high risk exposures will be managed by WA Health and may involve: making an EVD factsheet available (Appendices 13 and/or 14) exclusion of health care workers and those whose work involves direct physical contact with members of the public from working for 21 days from the date of last contact restriction from undertaking certain activities at the direction of DH person to take own temperature twice daily for 21 days from last exposure, preferably using a digital thermometer and oral readings, and to notify their local public health unit if febrile or unwell daily active monitoring by a public health unit officer by telephone any other actions required by WA Health. Follow-up for people with low risk exposures will be managed by WA Health and may involve: making an EVD factsheet available (Appendices 13 and/or 14) person to take own temperature twice daily for 21 days from last exposure, preferably using a digital thermometer and oral readings, and to notify their local public health unit if febrile or unwell any other actions required by WA Health. 18 Follow-up for people with an exposure assessed as casual contact will be managed by WA Health and may involve: making an EVD factsheet available (Appendices 13 and/or 14); any other actions required by WA Health. CDCD will inform the relevant PHU of patients under investigation, suspected, probable and confirmed cases of EVD. PHU Responsibilities If a PHU staff member becomes aware of a patient under investigation, suspected, probable or confirmed case of EVD before CDCD, they should contact CDCD immediately. PHUs will carry out their responsibilities in accordance with the Communicable Disease Network of Australia (CDNA) Ebolavirus Disease National Guidelines for Public Health Units. (http://www.health.gov.au/ebola) 1. Using the Ebolavirus Disease Case Report Form (Appendix 19), contact the patient‟s doctor to: confirm the onset date and symptoms of the illness confirm results of relevant pathology tests, or recommend that tests be done in accordance with local laboratory referral protocols find out if the case or relevant care-giver has been told what the diagnosis is before beginning the interview inform the doctor that public health staff will be contacting the patient/next of kin/carer. review case management including infection control measures being used in caring for the case. 2. Interview the case or care-giver to complete exposure and contact history and other details complete the exposure history and other sections of the EVD Investigation Form. identify close contacts according to the contact definition. 3. Follow-up patient‟s contacts to: assess risk of EVD transmission determine current symptoms, if any explain symptoms and need to immediately report any new symptoms explain to healthcare worker close contacts any need for work restrictions during the potential incubation period if there has been exposure provide an EVD Disease Factsheet and recommend any self-monitoring for relevant contacts. 4. Notify CDCD (if not already done) and update data on WANIDD and Epi Info. 5. CDCD will notify Commonwealth Department of Health, Office of Health Protection. 6. Refer all media to the Communications Directorate (08 9222 4333). 19 Appendix 5 – Infection prevention and control guidelines for Ebolavirus disease (non-quarantine hospitals) Guidance is provided in this Appendix for infection prevention and control of persons under investigation for Ebolavirus disease (EVD) and the subsequent management of those persons considered as suspected or probable cases of EVD in hospitals other than designated quarantine hospitals (Sir Charles Gairdner Hospital (SCGH) for adults and Princess Margaret Hospital (PMH) for children). Strict adherence to standard precautions and the adoption of transmission-based contact and droplet precautions is essential in the management of these patients. The two designated quarantine hospitals, SCGH and PMH, have specific policies and procedures in place for their respective settings. In healthcare settings, Ebolavirus is spread through direct contact (e.g. through broken skin or through mucous membranes of the eyes, nose, or mouth) with blood or body fluids of a person who is infected with EVD, or with objects (e.g. needles, medical equipment, environmental surfaces) that are contaminated with the virus. There is no epidemiological evidence that EVD is transmitted via the airborne route, however, due to the severe nature of the disease, more stringent precautions have been recommended. Correct application of personal protective equipment (PPE) that provides full body coverage (i.e. no skin exposure) and protection from potential aerosolized droplets is recommended to reduce the risk of direct or self-contamination. All HCWs providing care to suspected cases of EVD must have undertaken competency-based training on the correct application and removal of the designated PPE (Appendix 6 - Healthcare worker education and training resources). 1. Infection prevention and control for a ‘person under investigation’ Any person presenting to a non-quarantine hospital that meets the criteria for „a person under investigation‟ (Appendix 3), shall be asked to wear a fluid resistant surgical mask and placed in a negative pressure isolation room (NPIR) (also referred to as an „airborne infection isolation room‟) as soon as possible. If an NPIR is not available, use a single room. An initial risk assessment must be undertaken by the senior ED medical officer (MO). If the patient‟s condition allows, the initial risk assessment may simply be the taking of a history from the patient at a distance (greater than 2 meters), or may require physical examination if this is deemed appropriate, and this will govern the level of PPE required. If the patient can be interviewed and 20 assessed with no direct contact and a distance of >2m can be maintained, then no PPE is required. If direct contact with the patient is required, or the patient is symptomatic with vomiting or diarrhoea, the MO or HCW attending the patient should don PPE (gown, gloves, P2 or N95 mask, face shield and foot covers) while the initial risk assessment is undertaken. Following the initial risk assessment by the attending MO, this should be discussed with the on-call public health physician from the Communicable Disease Control Directorate (CDCD) who, in turn, will discuss with the on-call microbiologist from the designated quarantine hospital and make a final risk assessment. Following this final risk assessment, a decision will be made as to whether testing for EVD is indicated. Once a decision is made to test the patient for Ebolavirus, the patient changes from a „person under investigation‟ to a „suspected case‟. A decision will then be made to either transfer the patient to a designated quarantine hospital or continue to manage the patient in their current location. If the final risk assessment judges the patient not to have EVD, they can be managed in accordance with routine infection prevention and control precautions. 2. Infection prevention and control of a ‘suspected case’ of EVD Depending on the final risk assessment by the on-call public health physician from the CDCD and the on-call microbiologist from the designated quarantine hospital, the patient may remain isolated in the hospital ED to which they presented and have samples taken for urgent testing for EVD at PathWest QEII Laboratory (if deemed lower risk), or may be transferred immediately to the designated quarantine hospital (if deemed higher risk) (Appendix 11). Until such time as the patient is either transferred to the designated quarantine hospital or a negative result is returned for the lower risk patient who stays in situ, the infection prevention and control precautions described in the following sections (2.1-2.6) are the minimum required. Note that, owing to the higher risk that larger metropolitan hospitals will encounter a case of EVD, a pragmatic decision has been made for these hospitals to stock a limited number of higher level PPE ensembles for use in patients who have diarrhoea or vomiting (Jupiter hoods and powered air purifying respirators (PAPRs)). 2.1 Patient room placement, staff allocation and visitors Allocate patient to a NPIR with ensuite and ante room. If this preferred accommodation is not available, place in a single room with private bathroom or have a dedicated bathroom facility adjacent. The door should be closed. If a dedicated bathroom is not available, provide patient with urinal / commode using disposal products. Any fluid waste must be solidified prior to disposal in the clinical waste bin (Refer Appendix 9). 21 There needs to be clearly identified areas for the donning and doffing PPE. A HCW shall be assigned as a trained Observer and stationed outside the patient‟s room to monitor access, ensure consistent and appropriate PPE use and assist with donning of PPE. A second person, an Assistant, is required to help in doffing of PPE. Initiate a log of all HCWs entering the patient‟s room. Only essential medical and nursing HCWs are to enter the room and anteroom. HCWs who are immunocompromised, pregnant or those with non-intact skin e.g. dermatitis, abrasions are not to care for the patient. Stopping visitor access to the patient is preferred. If it is unavoidable, visitors must be restricted, registered in the log and be supplied with full PPE. 2.2 Hand hygiene Hand hygiene must be performed in accordance with the „5 Moments‟ and at nominated points in the donning and doffing of PPE. Hand hygiene can be performed by washing with antiseptic soap and water or by using alcohol based hand rubs. 2.3 Personal protective equipment (PPE) All HCWs entering the patient room, including the Assistant, are to change into disposable surgical scrubs prior to donning: o a pair of fluid-resistant disposable overshoes o knee high fluid-resistant boot/leg covers o fluid resistant hood to protect head and neck o single use long sleeved impervious (AAMI Level 4) gown o N95 or P2 mask – must be fit checked prior to entering the room. HCWs unable to achieve the correct fit should not enter the room. o disposable safety glasses o full face shield o double gloves – at a minimum the outer gloves should have long cuffs. The Observer is to remain outside of the room or at a distance from the Assistant and HCW who has provided care to the patient When exiting the room, PPE shall be carefully removed as per the Donning and Doffing Procedure Checklist (Appendix 7), following instruction one step at a time from the Observer. The Observer is to read each step out aloud, and the HCW and Assistant are to wait for each prompt before proceeding to the next step. 22 Care shall be taken not to contaminate one‟s eyes, mucous membranes or clothing with potentially infectious material. Any breach or contamination event must be reported immediately. All PPE should be discarded directly into the clinical waste bin as it is removed. All HCFs are to have donning and doffing procedure check lists to assist in this process (Appendix 7 - HCW education and training resources). 2.4 Patient care equipment Dedicated medical equipment (preferably disposable, when possible) should be used for the provision of patient care. Disposable linen is to be used and disposed of into clinical waste. Disposable crockery and utensils are to be used if required. Any non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and hospital policies. It is not to be re-used on another patient until a definitive diagnosis is made. In the event a patient is confirmed with EVD all reusable medical equipment is to be quarantined until advice is received from the Chief Human Quarantine Officer (CHQO). All waste generated within the room is to be disposed of into clinical waste bins. 2.5 Patient care considerations Limit the use of needles and other sharps wherever possible. If used, they must be handled and disposed of with extreme care by the user in a puncture resistant sharps container at point of use. Pathology testing suspected or probable cases will be undertaken after transfer to a quarantine hospital. Avoid performing aerosol generating procedures (AGPs) e.g throat swabs, suctioning, and intubation. If they are unavoidable, they must be performed in a NPIR, with restricted HCWs present who must be wearing a powered air-purifying respirator (PAPR). Conduct environmental surface cleaning following procedures. The patient may use the toilet. Toilet waste is to be managed in accordance with Appendix 9 - Waste treatment and disposal. If the patient is unable to use the toilet, disposable bedpans / urinals are to be used. The contents must be solidified by adding a sachet of absorbent granules and disposing of in clinical waste once solidified. (Appendix 9). 23 2.6 Environmental cleaning Cleaning and disinfection of the patient‟s environment is essential to minimise the risk of environmental contamination and subsequent transmission of the virus from environmental surfaces or patient care equipment. Following patient transfer to a QH, the following terminal cleaning is to be performed: HCWs involved in terminal cleaning are to wear full PPE as described in 2.3 and in addition chemical resistant neoprene rubber gloves. Nursing and medical HCWs are to ensure all disposable items in the room, including linen are contained in clinical waste bins and clean any reusable medical equipment with detergent followed by disinfectant wipes. Any blood or body fluid spills must be managed by nursing or medical HCWs and actioned as soon as possible (Appendix 8). Once the room is empty of all used items, staff responsible for cleaning, can perform a 2-step clean using detergent and water followed by disinfection with 0.5% (5,000ppm) sodium hypochlorite. All clinical waste and any reusable equipment are to be quarantined in the ante room or the patient room until notified of a confirmed diagnosis. If EVD is excluded, handling of clinical waste and patient equipment is per routine management. If a diagnosis of EVD is confirmed, any reusable equipment is to be managed as per 2.5 and disposal of the clinical waste is to be followed as per Appendix 9. 3. Death of suspected EVD case In the event a suspected case was to decease in a NQ hospital, refer to Appendix 10. 4. Management of HCWs following occupational exposure The management of a HCW who sustains an occupational exposure with blood or body fluids from a suspected EVD Case is described in Appendix 12. 24 Appendix 6 – Healthcare worker education and training resources for Ebolavirus disease All HCWs are be required to demonstrate competency in the use of PPE, including donning and doffing, before providing care to patients with suspected, probable or confirmed Ebolavirus disease. They must have received repeated training and have demonstrated competency while being observed by a trained observer in the correct application and removal of the designated personal protective equipment (PPE). Training ensures that HCWs are knowledgeable and proficient in the donning and doffing of PPE prior to engaging in management of patient with suspected, probable or confirmed Ebola. Comfort and proficiency when donning and doffing are only achieved through repeated practice on the correct use of PPE. In addition, during practice, HCWs and their trainers should assess their proficiency and comfort with performing required duties while wearing PPE. All HCFs are to ensure they have a register of HCW trained in accordance with the WA Health Ebolavirus Training Package and assessed as competent. The following resources are available at: [TBA] o WA Health Donning and Doffing Personal Protective Equipment Video 1 PPE with non-PAPR use Video 2 PPE with use of PAPR o WA Health Written Instructions and Checklist o WA Health Competency Certificate o WA Health PPE Descriptor Poster 25 Appendix 7 – Donning and doffing PPE procedures checklist 26 Appendix 8 - Cleaning and disinfection General The information in this Appendix primarily applies to those patients who have been categorised as probable or confirmed Ebolavirus disease (EVD) cases. The personal protective equipment (PPE) requirements for environmental cleaning are the same as those for patient care. There may be situations that require environmental cleaning of a residence or other non-hospital setting prior to the availability of laboratory test results for a suspected case with a high pre-test probability. This should follow the principles outlined in this Appendix, following discussion with public health authorities. Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is required as blood, sweat, vomitus, faeces and other body secretions represent potentially infectious materials. All staff carrying out cleaning and disinfection must be trained in the use of appropriate PPE and have been assessed as competent in the donning and removal of the PPE as described in Appendix 7 Donning and doffing PPE procedures checklist. In addition to the PPE described, staff performing cleaning, are to wear chemical resistant neoprene gloves which are to be discarded to clinical waste after each use. Disposable cleaning equipment is to be used and discarded into clinical waste bins after use. Disinfectants Ebolaviruses are readily inactivated by disinfectants that are active against other viruses such as norovirus and rotavirus. The preferred disinfectant solution is sodium hypochlorite made using powder sachets, granules or tablets to (0.1%) 1,000 ppm parts per million (ppm) available chlorine (follow manufacturer‟s instructions) for routine environmental cleaning and (0.5%) 5,000 ppm for spills. Neutral soaps and detergents should be used liberally for washing hands and the patient. Do not use disinfectants as part of routine patient washing. Routine environmental cleaning Daily clean of all hard, non-porous surfaces such as floors, toilets, counters, and high-touch surfaces (e.g. door handles, bed rails, light switches, call bells and tables) still applies and the room should be cleaned as per usual practice. Visibly soiled surfaces should be wiped clean with single use detergent cloths until visibly clean. A two-step clean is required: a daily clean with neutral detergent is required while the patient is in the 27 isolation room. All cleaned surfaces should then be disinfected using the freshly prepared sodium hypochlorite solution. Dispose of all cleaning cloths and mop heads into the clinical waste after each clean. The patient toilet should be cleaned with a 1,000 ppm sodium hypochlorite solution after each use, after the contents have been flushed. Terminal cleaning Terminal cleaning should be carried out as per routine cleaning. Prior to commencing the clean, the room is to be „stripped‟ i.e. ensure all disposable equipment, rubbish and linen is discarded into clinical waste bins and the containers sealed. Once the patient has left the room the entire room should be cleaned with a neutral detergent then allowed to air dry. Dispose of all cleaning clothes and mop heads into the clinical waste. Once the room is air dry repeat the cleaning process with a 1,000 ppm sodium hypochlorite solution and ensure the disinfectant is liberally applied to all surfaces within the isolation room. Dispose of all cleaning equipment including buckets, mop handles, mop heads, cloths into the clinical waste after a terminal clean. Allow the room to air dry. Where negative pressure is being used, maintain the negative pressure during the terminal clean. Then allow an additional 30 minute period after the room has air dried before switching off the negative pressure and allowing the next patient to enter the room. Any non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and hospital policies. It is not to be re-used on another patient until a definitive diagnosis is made. In the event a patient is confirmed with EVD, all reusable medical equipment is to be quarantined until advice is received from the on-call public health physician from the Communicable Disease Control Directorate. Spills management Any blood or body fluid spill must be contained and managed as soon as possible after the event has occurred. The HCW managing the spill must be wearing the same PPE as HCWs caring for the patient, which includes a pair of fluid-resistant disposable overshoes, knee high fluid-resistant boot/leg covers, fluid resistant hood to protect head and neck, single use long sleeved impervious gown, a fit-checked N95 or P2 mask, disposable safety glasses, full face shield and double, long-cuffed gloves (see 28 Appendix 6 - Infection prevention and control guidelines for Ebolavirus disease (non-quarantine hospitals)). Remove any bulk matter with disposable cloths and discard in clinical waste. Remove outer gloves, discard and perform hand hygiene with an ABHR. Don a new pair of outer gloves. Absorbent granules should be placed on the spill and covered with paper towels to limit the spread of the spill. Leave until all liquid is absorbed removing and disposing of the absorbed spill and paper towel. Limit the spread of the spill and remove any bulk matter by covering with absorbent paper towels or absorbent granules, liberally covered with a 5,000 ppm sodium hypochlorite solution and left to soak for 30 minutes before being wiped up. Leave until all liquid is absorbed removing and disposing of the absorbed spill and paper towels into clinical waste for disposal. Following the removal of the initial material, remove outer gloves, discard and perform hand hygiene with an alcohol-based hand rub. Don a new pair of outer gloves. The area of contamination should again be liberally covered with a 5,000 ppm sodium hypochlorite solution and left for 30 minutes before rinsing. Patient Equipment Limit the equipment that enters the patient‟s room. The patient must have their own dedicated equipment that remains with them for the duration of their hospitalisation. Use disposable products when available. When reusable non-critical equipment leaves the patient room ensure a two stage cleaning with a neutral detergent followed by a second clean with a 1,000 ppm sodium hypochlorite solution. For semi critical and critical equipment ensure routine disinfection/sterilization reprocessing occurs, no additional disinfection or sterilization cycle is required. Linen The use of disposable linen is preferable. Linen is treated as clinical waste. For linen wet from body fluids, place into a leak-proof bag and not a cloth linen bag. Patient clothing Patient clothing should be disposed of in the clinical waste. The patient should wear hospital clothing and gowns and not their own clothes. Patient clothing and linen must not be processed in a domestic washing machine. 29 Appendix 9 – Waste treatment and disposal This Appendix is based on waste treatment and disposal methods described in Appendix 13 of the Ebolavirus Disease (EVD) CDNA National Guidelines for Public Health Units, and incorporating recommendations from The Environmental Health Standing Committee (enHealth) [a standing committee of the Australian Health Protection Principal Committee (AHPPC)]. 1. Clinical waste, including bed linen, patient clothing disposable personal protective equipment and other waste The PPE requirements for personnel involved in environmental cleaning are the same as those engaged in patient care. All waste is to be treated as clinical waste. Any bulk liquid waste must be solidified using high absorbency granules prior to transfer to clinical waste bags. All waste to be disposed of in accordance with WA Health Clinical and Related Waste Management Policy and Operational Directive OD 0258/09 Clinical and Related Waste Management – General Requirements and OD 0259/09 (Clinical and Related Waste Management – Clinical Wastes). All items are to be double-bagged in clinical waste bags that adhere to Australian Standards and be leak proof. Facilities should have a system of double bagging the clinical waste which should involve keeping the first clinical waste bags inside the patient room and then placing these bags inside a second clinical waste bag kept outside the patient room. Waste bags must then be placed inside rigid puncture-proof and sealable containers, which in turn should be disinfected with sodium hypochlorite made up to 1,000 parts per million (ppm) available chlorine. Prior to collection by the contractor, waste must be stored securely and access restricted to authorised and trained personnel. High-temperature incineration is the approved method for disposal. Other disposal methods will require specific DOH approval [as of 24 October 2014, enHealth is reviewing whether autoclaving of clinical waste followed by transport to approved landfill transport facilities is to be permitted, and 30 standards/evidence required for approval of any disposal method other than high-temperature incineration]. 2. Effluent waste and toilet procedure International (WHO, CDC) and National (CDNA EVD National Guidelines for Public Health Units) EVD guidelines recommend that effluent waste can be safely disposed of direct to mains sewer and septic systems. However, enHealth recommends that additional measures such as addition of chlorine in a suitable concentration for a spill to the toilet waste [e.g. Milton tablets (1% sodium hypochlorite) = 10,000 ppm available chlorine] and allowing up to 30 minutes, prior to flushing provides further surety in the unlikely event of a breach of mains sewer in close proximity to the treating hospital or hospital wastewater infrastructure. Where possible, automatic chlorine dosing of toilets or by hospital staff with appropriate PPE to clean (P2/N95 mask and PPE) as per guideline as opposed to relying on the patient to undertake these steps, as well as frequent cleaning and a cleaning schedule to be displayed inside room. In all cases, ensure the toilet lid is down when flushing. If staff are required to flush the toilet, it is recommended they wear a P2/N95 mask in addition to their other PPE in case of aerosols when the toilet is flushed. If a patient is unable to use the private bathroom, a disposable pan should be used. The contents of the pan are to be solidified with high-absorbency gel then both the pan and contents disposed into clinical waste. The patient toilet should be cleaned with a 1000ppm sodium hypochlorite solution after each use with lid closed, after the contents have been flushed. 3. Waste companies transporting contaminated waste All waste should be considered as clinical waste. Double-bagged waste to be placed in a rigid puncture-proof container, sealed, then surface disinfected prior to transport. 4. Non-hospital setting decontamination Ambulance and patient vehicle decontamination: Apply WHO standard for washing of vehicles using non-hose or aerosol generating method, including use of PPE, debulking of blood or other 31 body fluids, or spills ( and wiping and soaking, with disposal into clinical waste) in the vehicle and use of with sterilising spray. Avoid high pressure spray due to risk of aerosols. These procedures to be carried out using Ambulance companies‟ own washdown facility or that of a hospital, and liquid waste produced as a result of decontamination and cleaning of patient transport vehicles, must be disposed of down drains that lead to a holding tank that can be sterilised, or to mains sewer. Private residences or other accommodation: whenever possible, decontamination of potentially infected homes should be delayed by 6 days to allow denaturing of infectious virus particles, thereby reducing risk of exposure. However, this may not be possible with potential EVD cases due to public attention or home quarantine. In these circumstances, infection control personnel, first responders (e.g. fire fighters or police cleaning crews) and/or other contracted entities should undertake decontamination methods consistent with CDNA EVD National Guidelines for Public Health Units. Focus on disposal or of porous items and disinfection of non-porous items. EVD appears not be viable outside the human or animal body beyond six days, so to provide additional surety, premises should be vacated for at least seven days prior to re-occupation. 5. Mortuary waste See Appendix 14 of CDNA EVD National Guidelines for Public Health Units and NHMRC Infection Control Guidelines outline procedures post-mortem care and disposal of the deceased. 6. Funeral premises All mortuaries must be constructed according to requirements in National Construction Code with drainage to sewer. 7. Training body handlers such as hospital staff and funeral directors Apply standard outlined in CDNA national guidelines for EVD, noting that while cremation is preferred, immediate burial is permissible. 32 Appendix 10 – Post-mortem care and examination Definitions for terms used in this appendix Cremation: The act of reducing human remains to ash by intense heat. Leakproof bag: A body bag that is puncture-resistant and sealed in a manner so as to contain all contents and prevent leakage of fluids during handling, transport, or shipping. Safe handling of human remains of a patient with Ebolavirus disease These recommendations give guidance on the safe handling of human remains that may contain Ebolavirus and are for use by personnel who perform care of the deceased in hospitals and mortuaries. In patients who die with Ebolavirus infection, virus can be detected throughout the body. Ebolavirus can be transmitted by laceration and puncture with contaminated instruments used during post-mortem care, through direct handling of human remains without appropriate personal protective equipment, and through splashes of blood or other body fluids (e.g. urine, saliva, faeces) to unprotected mucosa (e.g. eyes, nose, or mouth) which occur during care of the deceased. The following are important principles of care in these circumstances: Only personnel trained in handling infected human remains, and wearing PPE, should touch, or move, any Ebola-infected remains or suspected Ebola-infected remains; Handling of human remains should be kept to a minimum; Post-mortems should not be performed on patients who die with Ebolavirus disease. If a postmortem is requested, the CDCD and PathWest Forensic Pathology should be consulted. Roles and responsibilities in the care of the deceased The completion of a death certificate by a medical practitioner is a vital part of the notification process of a death to the Registrar of Births, Deaths and Marriages and enables an authority to be provided to the funeral director to arrange disposal of the deceased. Completing a death certificate and reporting a death to the Coroner are mutually exclusive exercises. Doctors should be familiar with the criteria for reporting deaths to the Coroner. A death as a result of Ebolavirus disease would not ordinarily be reported to a Coroner. If a diagnosis of Ebolavirus disease has been made prior to death and there are no other criteria for reporting the death, a death certificate could be completed. Personal protective equipment for care of the deceased Personal protective equipment (PPE): Prior to contact with the deceased, post-mortem care personnel must wear at least the following PPE: impervious gown with full sleeve coverage, eye protection (e.g. 33 face shield, goggles), single use sub-micron fluid resistant facemask, shoe covers, and double gloves. Additional PPE (leg coverings, apron) might be required in certain situations (e.g. copious amounts of blood, vomit, faeces, or other body fluids that can contaminate the environment). Putting on, wearing, removing, and disposing of protective equipment: PPE should be in place BEFORE entering the room, contact with the deceased, worn during the process of collection and placement in body bags, and should be removed immediately after and discarded as regulated medical waste. Use caution when removing PPE as to avoid contaminating the wearer. Hand hygiene (washing your hands thoroughly with soap and water) should be performed immediately following the removal of PPE. Preparation of the deceased Preparation of the deceased: All contact with the deceased should be minimized. At the site of death, the deceased should be placed in leak-proof body bag not less than 150 μm thick and zippered closed. Change your gown or gloves after placing the deceased in the bag. Leave any intravenous lines or endotracheal tubes that may be present in place. Avoid washing or cleaning the deceased. The bagged remains should then be placed in another leak-proof plastic body bag not less than 150μm thick and zippered closed before being transported to the morgue. Surface decontamination: Prior to transport to the mortuary, perform surface decontamination of the outer body bag by first removing visible surface contamination on bag surfaces with recommended disinfectants which can kill a wide range of viruses. An example of an effective disinfectant is sodium hypochlorite (Appendix 8). Follow the product‟s label instructions. After any visible contamination has been removed, reapply the disinfectant to the entire bag surface and allow to air dry. Following the removal of the body, the patient room should be cleaned and disinfected. Reusable equipment should be cleaned and disinfected according to standard procedures. For more information on environmental infection control, please refer to “Interim Guidance for Environmental Infection Control in Hospitals for Ebolavirus” (http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-controlin-hospitals.html). Individuals driving or riding in a vehicle carrying deceased persons: PPE is not required for individuals driving or riding in a vehicle carrying deceased persons, provided that drivers or riders will not be handling the body and the body is safely contained in a disinfected body bag as described above. Mortuary Care Do not open the body bags and do not remove remains from the body bags. Bagged remains should be placed directly into a sealed casket. 34 Do not perform embalming. The risks of occupational exposure to Ebolavirus while embalming outweighs its advantages; therefore, bodies infected with Ebolavirus should not be embalmed. Mortuary care personnel should wear at least the PPE listed above (surgical scrub suit, surgical cap, impervious gown with full sleeve coverage, eye protection (e.g., face shield, goggles), facemask, shoe covers, and double gloves) when handling the bagged remains. In the event of leakage of fluids from the body bag, thoroughly clean and decontaminate areas of the environment with recommended disinfectants (refer Appendix 6). Reusable equipment should be cleaned and disinfected according to standard procedures. For more information on environmental infection control, please refer to Interim Guidance for Environmental Infection Control in Hospitals for Ebolavirus (http://www.cdc.gov/vhf/ebola/hcp/environmental-infectioncontrol-in-hospitals.html). Disposition of remains There should be no viewing of the deceased by family members. The body bags and casket should remain sealed. Remains should be cremated or buried promptly in a sealed casket. Once the bagged body is placed in the sealed casket, no additional cleaning is needed unless leakage has occurred. As an additional precaution gloves should be worn when handling the sealed casket. No PPE is needed when handling the cremated remains. The Australian Funeral Directors Association, Funeral Industry Infection Control Guidelines, 2008 can be obtained from: http://afda.org.au/media/member/ICG.pdf Transportation of human remains Transportation of remains that contain Ebolavirus should be minimized. Reported deaths CDCD will be alerted if Police who attend a reported death suspect that a deceased person may have Ebolavirus disease. If the deceased was reported to have flu like symptoms immediately prior to death and has recently travelled to an affected area in Africa, CDCD will notify the SCGH on-call microbiologist and the PathWest Forensic Pathology on-call pathologist. PathWest Forensic Pathology will advise Police to secure the scene and await further advice. PathWest Forensic Pathology‟s on-call pathologist, in consultation with CDCD and the SCGH on-call microbiologist will make the decision to either treat the deceased as “suspected Ebola” or a normal case. PathWest Forensic Pathology will also notify the Chief Health Officer and the State Coroner immediately. 35 If the decision is made to treat the deceased as “suspected Ebola” the deceased is to remain in situ and a PathWest Forensic Pathology Pathologist with appropriate PPE will attend the scene and collect appropriate specimens in accordance with Appendix 18. References Centers for Disease Control and Prevention, Guidance for Safe Handling of Human Remains of Ebola Patients in Hospitals and Mortuaries. Available from: http://www.cdc.gov/vhf/ebola/hcp/guidancesafehandling-human-remains-ebola-patients-us-hospitals-mortuaries.html 36 Appendix 11 - EVD patient transfer and transport guidelines Assessing need for transfer of a suspected case to a designated hospital The following patients will generally be transferred to the designated quarantine hospitals as a matter of urgency – Sir Charles Gairdner Hospital (SCGH) for adult cases, including pregnant women, and Princess Margaret Hospital (PMH) for child cases: a confirmed case of Ebolavirus disease (EVD) a suspected case of EVD with high risk exposures and a highly consistent clinical picture. The following factors are likely to favour immediate transfer to SCGH/PMH before confirmation of EVD and should be considered in a discussion between the on-call public health physician from the Communicable Disease Control Directorate (CDCD), the on-call microbiologist from SCGH/PMH, and the referring practitioner: Higher likelihood of EVD: o clinical features highly consistent with EVD in the opinion of an infectious diseases specialist (such as unexplained haemorrhage) o one or more high risk exposure(s) (for definitions, see Ebolavirus Disease (EVD) CDNA National Guidelines for Public Health Units Criticality of patient allied to need for urgent pathology: o patient is critical or requires intensive care o urgent need for general pathology. Lower negative predictive value of initial testing to exclude EVD: o timeframe since onset of illness is less than 72 hours o indeterminate result on initial testing. Lower capability of health service to handle a suspected case: o health service does not have appropriate infection prevention and control capability; o health service does not have infectious diseases expertise. A case that is to be transferred to SCGH/PMH after consideration of the above factors will have all testing including for EVD and routine pathology conducted at the receiving hospital. For patients who are deemed appropriate to remain at the presenting health facility, specimens will be collected at that facility for transport to PathWest QE II Laboratory at SCGH for EVD testing and routine pathology should be avoided until EVD is excluded. 37 Transfer arrangements Transfers will be activated by the on-call CDCD public health physician and the on-call microbiologist in consultation with the most appropriate transport provider, i.e St John Ambulance or Royal Flying Doctor Service. A medical practitioner should not organise transfer of a patient with suspected or confirmed EVD unless the situation is critical and the on-call CDCD public health physician has not been able to be contacted for any reason. St John Ambulance and Royal Flying Doctor Service are equipped to transfer suspected or confirmed cases of EVD in WA. St John Ambulance and Royal Flying Doctor Service will use infection prevention and control precautions including standard, contact and droplet precautions for the transfer of suspected cases. Where there are copious amounts of blood or body fluid present, additional PPE may be required as described in the section on Infection prevention and control. For a paediatric patient requiring specialised retrieval, PMH will coordinate retrieval through the Newborn Emergency Transport Service of Western Australia. 38 Appendix 12 – Management of healthcare workers following occupational exposure 39 Appendix 13 - Ebolavirus disease fact sheet What is Ebolavirus Disease (EVD)? Ebolavirus Disease (EVD) is a serious and often fatal disease caused by a virus. There are several strains of the virus. EVD was previously called Ebola haemorrhagic fever. Fruit bats are considered to be the natural host of Ebolaviruses, with outbreaks amongst other species such as chimpanzees, gorillas, monkeys and forest antelope from time to time. There have been 24 outbreaks in humans of EVD in Central and East Africa since the virus was first identified in 1976. While there is evidence of one strain of Ebolavirus being present in animal populations in some parts of Asia, there have been no reports of human illness outside of Africa. The current outbreak is the first in West Africa. There is no evidence that it is present in Australian bats or other animals in Australia. There have been no cases in Australia. What are the symptoms? Ebolavirus can cause a serious illness, with a sudden onset of fever, muscle and joint aches, weakness, and headache. The next stage is characterised by vomiting, diarrhoea, rash and malfunction of liver and kidneys. Some cases present with profuse internal and external bleeding and progress to multi-organ failure. Between 50 and 90% of cases of EVD will die of the disease. How is it spread? Ebolavirus is introduced into the human population through close contact with the blood, secretions, organs or other bodily fluids of infected animals (e.g. through the hunting or preparation of "bushmeat"). Ebolavirus then spreads from person to person via contact with the blood, secretions, or other bodily fluids of infected people, and contact with environments contaminated with such fluid, including in healthcare settings. Transmission through sexual contact may occur up to three months after clinical recovery. Airborne transmission is not known to occur. Traditional burial ceremonies conducted in affected areas of Africa are a known high risk activity for transmission. 40 Who is at risk? People who are living in or travelling to affected areas of Africa may be at risk of infection; however, the risk of infection is extremely low unless there has been direct contact with the bodily fluids of an infected person or animal (alive or dead). Caring for ill relatives is a known risk factor for infection, and healthcare workers, particularly those in resource poor settings with inadequate infection control are also at risk. How is it prevented? Good hygiene and infection control around EVD cases is the only way to prevent spread of disease. There is no vaccine for EVD. Hunting and contact with "bushmeat" in affected areas should be avoided. What should I do if I become unwell after travel in areas affected by EVD? If you become ill or feel unwell while travelling in areas affected by EVD, you should not wait until you arrive back in Australia to seek medical assistance. Instead you should see a doctor or go to the local emergency department. If you have returned within the last 21 days from travel to areas affected by EVD and develop a fever, vomiting, diarrhoea and other symptoms, you should see your doctor or go to the emergency department to work out why you are ill. It is important that you mention your symptoms and which countries you have visited when you first arrive at the medical practice or hospital emergency department. You may be separated from others to prevent further spread of infection. How is it diagnosed? EVD is diagnosed by a blood test that detects the virus. Urine and/or a swab from throat or nose may also be examined to look for the virus. Testing for EVD is done in a public health laboratory with special biosafety facilities. How is it treated? There is currently no specific treatment for people who are sick with EVD, but general intensive medical care can be life-saving. What is the public health response? Special procedures to prevent the spread of EVD are in place to manage the situation in the event there is a case of EVD in Australia. These include: 41 Doctors and laboratories are required to notify state/territory health departments of any suspected cases. Isolation of suspected cases from other people. Identification of people who have been in contact with the case by Public Health authorities so that these people are given information about the risk of infection and monitored for any signs or symptoms of the disease. Special safety guidelines including wearing protective equipment to prevent spread of Ebolavirus to health care workers managing cases and laboratory staff handling specimens. Public health unit staff will investigate all cases to find out how the infection occurred, identify other people at risk of infection, implement control measures and provide other advice. Further information World Health Organization (WHO) EVD updates available from the WHO website: (www.who.int/csr/disease/) Australian Department of Health – EVD website (https://www.health.gov.au/ebola) 42 Appendix 14 - Fact sheet for contacts of a person with Ebolavirus disease 43 Appendix 16 - Contact numbers DEPARTMENT OF HEALTH, WESTERN AUSTRALIA, AFTER HOURS EMERGENCY CONTACT NUMBERS OFFICER TELEPHONE TELEPHONE (OFFICE HOURS) (AFTER HOURS) WA Chief Human Quarantine Mob: 0429 153 201 Mob: 0429 153 201 Officer Tel: (08) 9388 4800 or Dr Paul Armstrong Fax: (08) 9388 4888 Tel: (08) 9328 0553 Manager - State Ambulance Tel: (08) 9334 1234 Tel: (08) 9334 1234 Operations Fax: (08) 9334 1207 Fax: (08) 9334 1207 Mob: Mob: St John Ambulance Duty Manager 0434 664 413 0434 664 413 Australian Government Airport Managers Department Of Agriculture Mob: 0434 305 895 (formerly AQIS) Mob: 0434 664 414 Perth Airport Duty Manager Tel: (08) 9478 8501 Tel: (08) 9478 8501 (24 hrs) Westralia Airports Corporation Fax: (08) 94788590 Control Centre: Perth International Airport Tel: (08) 9478 8572 Fax: (08) 9478 8574 Perth Airports Emergency Tel: (08) 9478 8816 Planning Manager Fax: (08) 9478 8889 Manager, Safety Mob: 0477 114 115 Fremantle Port Authority Tel: (08) 9432 3660 Mob: 0439 977 820 Mob: 0477 114 115 Fax: (08) 9336 1391 Office of Health Protection Director, Human Quarantine Duty Officer – National Incident (Commonwealth Department of Tel: (02) 6289 8408 Room - 24 hour service Health and Ageing) Fax: (02) 6285 1994 or Tel: (02) 6289 3030 Director, Border Health Fax: (02) 6289 3040 Tel: (02) 6289 2705 Fax: (02) 6289 2600 44 STATE HUMAN QUARATINE OFFICERS, WESTERN AUSTRALIA OFFICER TELEPHONE (OFFICE HOURS) TELEPHONE (AFTER HOURS) Dr Gary Dowse (Communicable Disease Control Directorate) Mob: 0408 917 799 Tel: (08) 9388 4849 Tel: (08) 9328 0553 Dr Paul Effler (Communicable Disease Control Directorate) Mob: 0407 727 131 Tel: (08) 9388 4818 Tel: (08) 9328 0553 Dr Donna Mak (Communicable Disease Control Directorate) Mob: 0437 781 930 Tel: (08) 9388 4828 Tel: (08) 9328 0553 Dr A Keil (Princess Margaret Hospital) Tel: (08) 9340 8222 Fax: (08) 9380 4474 Tel: (08) 9340 8222 (PMH switchboard) Dr D Smith (PathWest) Tel: (08) 9383 4438 Tel: (08) 9346 3333 (switchboard) Fax: (08) 9346 3960 Tel: (08) 9346 2536 (PathWest Security) Dr T Inglis (PathWest) Tel: (08) 9383 4548 Tel: (08) 9346 3333 (Page 4450) Fax: (08) 9382 8046 Tel: (08) 9346 2536 (PathWest Security) Dr Marissa Gilles Public Health Physician WACHS – Midwest Mob: 0429 086 740 Tel: (08) 9956 1985 Tel: (08) 9328 0553 Dr Clare Huppatz Public Health Physician WACHS – Goldfields Mob: 0408 917 799 Tel: (08) 9388 4849 Tel: (08) 9328 0553 Dr Heather Lytlle Public Health Physician WACHS – Pilbara Mob: 0409 170 056 Tel: (08) 9080 8200 Tel: (08) 9328 0553 Dr Naru Pal Public Health Physician WACHS – South West / Gt. Southern Mob: 0429 686 998 Tel: (08) 9842 7500 Tel: (08) 9328 0553 45 Appendix 17 – Specimen collection and handling Appendix 18 – WA EVD laboratory testing guidelines 46 Appendix 19 - Ebolavirus Disease Case Report Form 47 This document can be made available in alternative formats on request for a person with a disability. © Department of Health 2014 Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.
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