Download Guideline For The Management And Control Of

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:
December 2014
Version Number:
V 2.3
Review Date:
November 2016
Responsible Person
Josephine Pravinkumar
Version No.2.3
December 2014
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Management of Viral Haemorrhagic Fevers
CONTENTS
i)
Consultation and Distribution Record
10)
Change Record
1.
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 (Nov 2014)
Appendix 2: Patient Pathway
Appendix 3: Infection Control Precautions – VHF
Appendix 4: Checklist for Consultant Microbiologists when alerted regarding the
possibility of a patient with VHF
Appendix 5: Protocol for Blood Sampling for Patients with Possibility of VHF
Appendix 6: Categorisation and Management of Contacts
Appendix 7: WHO (2014) Correct Method of putting on and removing PPE and HPS
PPE Training Slides
Appendix 8: Guidance for Waste Management
Appendix 9: Contact Tracing Record
Additional Documents for Reference:
Ebola Clinical Guide Infographic
Ebola and Infectivity
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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



Biochemistry laboratory staff
Consultant Microbiologist
Emergency Department consultant and Receiving Units

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



General Practitioners (GP)
Haematologists
Infection control staff
Infectious Diseases (ID) consultant & ID Unit staff
Mortuary staff
PSSD



Public Health
Salus
Scottish Ambulance Service

NHS Lanarkshire intranet – Firstport

NHS Lanarkshire internet
CHANGE RECORD
Date
22/11/2013
10/02/2014
18/03/2014
20/03/2014
Author
Lindsay Guthrie
Lindsay Guthrie
Lindsay Guthrie
Lindsay Guthrie
01/04/2014 Lindsay Guthrie
28/04/2014 Lindsay Guthrie
17/07/2014 Lindsay Guthrie
28/08/2014 Josephine
Pravinkumar
10/09/2014 Lindsay Guthrie
09/10/2014 Lindsay Guthrie
14/10/2014 Josephine
Pravinkumar
17/10/2014 L Guthrie
12/11/2014 L Guthrie /
J Pravinkumar
28/11/2014 J Pravinkumar
23/12/2014 J Pravinkumar
Version No.2.3
Change
Content revised to reflect DoH guidance
Final version for approval
Updated to reflect updated ACDP guidance
Updated to reflect Laboratory comments &
updated guidance
Final version for approval
Updated to reflect SAS VHF policy –
change to information re transfer of patients
Updated to reflect updated HPS algorithm
Updated to reflect updated ACDP guidance
Version No.
V0.2
V1.0
V1.1
V1.2
Updated to reflect revised guidance
Updated algorithm, guidance and to reflect
comments from of table top exercise
Updated guidance to reflect comments from
ID unit staff and exercise participants
Interim version with further changes
Updated version to reflect national guidance
and local discussion and arrangements
Updated to reflect ACDP guidance
Updated to reflect local arrangements
V1.7
V1.8 & 1.9
December 2014
V1.3
V1.4
V1.5
V1.6
V1.10
V2.0
V2.1
V2.2
V2.3
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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
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3.2
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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 Unit
Emergency Departments
Consultant Microbiologist
Infection Control Staff
Department of Public Health
General Practitioners
PSSD
Mortuary staff
Scottish Ambulance Service
Salus
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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
Clinical
manifestation
Incubation period
Period of
infectivity
Mode of
transmission
Reservoirs
Population at risk
Notifiable disease
Version No.2.3
Of 15 viral agents, 4 are more commonly known:
 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
Experimental evidence suggests that the virus can survive on
surfaces in lower temperatures for over three weeks
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.
Yes
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4.2
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 fever of unknown origin, or a history of fever 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 affected area or 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, Mali, Congo DR 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 or eaten 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 AND the patient has no history of bruising, active bleeding,
vomiting or diarrhoea, 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 Ebola Response
Roadmap
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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 on page 6
N.B. With this classification, a patient is no longer suspected of having VHF, and as
such additional PPE and patient isolation are no longer required (unless they are
needed for other clinical reasons). There is also no need for a VHF laboratory
communication cascade or a teleconference with the Scottish Ambulance Service.
However, if the patient’s risk classification is ever upgraded to “Low Possibility” or
“High Possibility”, then the appropriate guidance as shown in this document should
be followed. An example where this may occur is when an individual is initially
asymptomatic after returning from a VHF endemic country, therefore is “unlikely to
have a VHF”, but subsequently becomes symptomatic.

Low Possibility – (1) answers yes to question A, but (2) answers no to question B
and all stated additional questions and (3) does not have extensive bruising or
active bleeding.

High possibility – (1) answers yes to question B, or (2) answers yes to question A
and any additional question (3) and/ or has extensive bruising or active bleeding.

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. A sample contact tracing form is available as Appendix 9 to
record list of contacts that may have been inadvertently exposed to a high possibility case.
The Consultant Microbiologist will liaise with the Imported Fever Service at Public Health
England to discuss VHF screening as appropriate: Telephone 0844 7788990.
From 1st December 2014, a Scottish VHF testing service is available for testing samples
of “high possibility of VHF” using molecular (real time PCR) approaches. A checklist
summarising the actions for Consultant Microbiologists is available as Appendix 4.
4.2.1
MANAGEMENT OF PATIENT IN PRIMARY CARE
All suspected Ebola cases that present to primary care should be discussed with
the ID Consultant who will lead the risk assessment and arrange clinical review.
Individuals that telephone the surgery or walk-in centre and report that they are unwell and
have visited an affected area in the past 21 days must be told not to visit the surgery or
walk-in centre. The patient should be called back as soon as possible by the GP or duty
doctor to risk assess prior to discussion with the ID Consultant.
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Surgeries, out of hours’ centres and walk in centres should clearly display information requesting patients to tell the receptionist on arrival if they are unwell and have returned from
an Ebola-affected area within the last 21 days. Any patients identifying themselves to
reception staff should not sit in the general waiting room once Ebola is considered a
possibility. These patients should be isolated in a single side room immediately to limit
contact, and urgent clinical advice sought from the ID Consultant.
If at the time of a consultation it becomes apparent that Ebola may be a possibility then the
attending primary care clinician should take immediate steps to isolate the patient to limit
further contact and seek advice from the ID Consultant. Hand hygiene is an important
infection control measure; the Ebola virus is not a robust virus, and is readily inactivated,
for example, by soap and water or by alcohol. It is important to remember that
transmission of Ebola from person to person is only through direct contact with the blood
or body fluids of a symptomatic infected person.
There is no evidence of Ebola transmission through intact skin or through small droplet
spread, such as coughing or sneezing. Cleaning and decontamination of any rooms in
which a suspected or confirmed Ebola patient has been isolated or any facilities used by
the patient should be discussed with the local Health Protection Team.
Further information for GP practices can be found on the Health Protection Team Firstport
page.
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 (TBPs):
 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.
Additional Information for Reference
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Appendix 7 - WHO (2014) Correct Method of putting on and removing PPE and HPS PPE
Training Slides
Appendix 8 - Waste Management Guidance
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4.4
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. The only exception to this is blood glucose
(capillary testing) testing for diabetics.
All samples should be sent to the appropriate laboratories for processing and the
laboratory staff advised, before sending samples, of a possible diagnosis of VHF. The
receiving laboratory should telephone the ward to confirm receipt of samples. Specimens
from patients who have a high possibility of confirmed VHF should only be requested
following discussion with the ID Consultant.
Routine biochemistry/haematology tests can be taken and sent (with prior notification) to
the laboratories whilst awaiting the outcome of the malaria film.
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
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To minimise the risk to staff, the following must be observed:
 Laboratory staff MUST be informed of specimens BEFORE THEY ARE SENT
 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 the Emergency Department / 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.
Specimen handling for VHF investigations
 Non essential samples (urine, stool and sputum) will only be processed after
discussion between Consultant Microbiologist and Infectious Diseases (ID)
Consultant.
 It has been agreed that patients with a high possibility of VHF should receive
unmatched Group O Rh (D) Negative red cells and Group AB FFP/CRYO without
any pre-transfusion serological testing if their clinical situation demands transfusion
support.
 Samples must be transported to the laboratory by clinical staff and handled
directly to the Microbiology BMS staff to the named person expecting the sample
 No samples should be left unattended in the Laboratory reception
 All samples must be processed in the Category 3 Containment Laboratory
 Laboratory forms must accompany the specimen to the category 3 laboratory. Data
entry into the Laboratory Information System must be performed in Category 3. No
forms should be scanned or leave the Category 3 facility
 Blood tubes or blood culture bottles that are visibly contaminated with blood or are
leaking will not be accepted and repeat samples will be required
 Visibly soiled forms should not be accepted and the ward should inform to provide a
repeat form asap
 Appropriate disinfection of sample containers should be performed prior to handling
the sample.
 Containers and left over sample must be disposed as hazardous waste and
incineration and autoclave. Samples should not be kept after processing
 Appropriate PPE must be used in accordance with the laboratory Standard
Operating Procedure.
Adherence to the NHSL Standard Operating Procedure (SOP): Guidelines for Processing
Samples Potentially Infected with Viral Haemorrhagic Fever is expected when handling
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samples from these patients. Use of personal protective equipment (PPE) in accordance
with the SOP is required when processing specimens.
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
Appendix 5 provides a summary of the steps involved in taking blood samples from
patients with a possibility of VHF.
Retrieval of specimens
If the possibility of VHF is realised after specimens have been sent, it is the responsibility
of the Consultant Microbiologist 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
The ID Consultant in charge of the patient will contact the Consultant Microbiologist to
inform of the possibility of VHF. The Consultant Microbiologist will cascade this information
to the relevant Consultant Biochemist and Haematologist to alert them.
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
4.6 PATIENT TRANSPORT
GPs 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 VHF.
VHFs are classified as Ambulance Category 4 infectious diseases across all Ambulance
Services in the UK.
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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.
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.
4.6.1
INTERNAL TRANSFER OF PATIENTS
Patients admitted via the Emergency Department may be required to be transferred
internally to Ward 2 (MGH) Infectious Diseases Unit following the NHS Lanarkshire
radiation procedure.
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4.7 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
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.
 Viewing of the deceased should be avoided.
 Where the body of a confirmed or suspected VHF patient is not in an isolator, staff
wearing suitable PPE should place the body inside double-sealable leak-proof body
bag, with absorbent material between each bag. 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.
 Post mortem examinations should not be performed
 Blood sampling can be undertaken by a competent person to confirm or exclude
VHF diagnosis
 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
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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.
4.8 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
01980 612100 (24hr)
Public Health England (previously
HPA)
Scottish Ambulance Service
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01236 748 748
03333 990125 (24 hrs)
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Centre (ask for duty manager)
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
01355 584956 (during
working hours)
01698 858254 (during
working hours)
4.10 PUBLIC HEALTH MANAGEMENT
On notification of any confirmed case of VHF, the duty Consultant in Public Health
Medicine will convene and chair an Incident Management team (IMT). An IMT may also be
considered for managing high possibility cases.
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.
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Management of Viral Haemorrhagic Fevers
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
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 high possibility 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 6.
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)
 Waste disposal costs (incineration)
 Additional consumables
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Management of Viral Haemorrhagic Fevers
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.
9.
EQUALITY & DIVERSITY ASSESSMENT
√
This policy meets NHS Lanarkshire’s EDIA
(tick box)
10.
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 list of FAQs is available on the Health Protection Team page on Firstport:
http://firstport2/staff-support/public-health/health-protectionteam/Latest%20Topic/FAQs.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
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
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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
For Additional Information see Scottish Supplement to ACDP Guidance:
http://www.documents.hps.scot.nhs.uk/travel/VHF/ebola-scottish-supplement-nov2014.pdf
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Appendix 1 – VHF decision making algorithm (Nov 2014)
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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 Mali
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
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Provide
contact list to
CPHM/ ID
Consultant
YES
Patient is
at GP
practice/in
hospital?
NO
GP/Hospital clinician to
notify on-call ID
Consultant* / Paediatric
Consultant who will lead
the risk assessment
VHF still
actively
considered?
NO
Patient with:
 Fever
 Travel in past 3 weeks to
a VHF affected area or
endemic country
GP/Hospital clinician to
compile list of contacts
ID / Paediatric Consultant to provide GP
with advice on patient management as
per standard referral pathway for
managing febrile travellers – malaria
needs to be excluded
Page 21 of 35
GP/ Hospital
Clinician or ID
Consultant to
notify CPHM
YES
*If Ebola is suspected
in a pregnant woman,
the on call Consultant
Obstetrician should be
involved in the risk
assessment and
clinical management
ID / Paediatric
Consultant liaise with
SAS to arrange patient
transport & admission
to Monklands
Hospital ward 2/
local or regional
Paediatric ward
(Patient must not use
public transport)
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 VHF Infection Prevention & Control precautions summary version 2.0)
Control Measure
Low possibility case
High Possibility case
Confirmed VHF case
Criteria
The patient has no bleeding/bruising or
uncontrolled vomiting or diarrhoea
The patient is categorised as High
Possibility of VHF – may or may not be
bleeding/ have uncontrolled vomiting or
diarrhoea
The patient has a positive VHF test and
may or may not be bleeding/ have
uncontrolled vomiting or diarrhoea
Isolate immediately in single room with ensuite or dedicated commode
Isolate immediately in single room (Negative
pressure and ante room where possible) with
en-suite or dedicated commode
Isolate immediately in negative pressure
isolation room with ante-room and en-suite or
dedicated commode
OR
AND
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
ID Consultant to arrange urgent transfer to
HLIU at Royal Free Hospital, London if
clinically appropriate
(if bruising/bleeding/vomiting/diarrhoea –
manage as High Possibility for VHF)
Patient placement
(Accommodation)
OR
ID Consultant to arrange urgent transfer to
High Level Isolation Unit (HLIU) –Royal Free
Hospital, London if clinically appropriate
Staffing/contact with
people
Limit contact with other people
Clinical staff only (no domestics etc) - Clinical staff to perform routine cleaning
Limit the number of HCWs who come into contact with the patient
Keep up to date list of staff who enter the room and who have been in contact with the patient
throughout their care for possible contact assessment.
Restrict non-essential personnel and visitors from the patient care area.
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Control Measure
Management of Viral Haemorrhagic Fevers
Low possibility case
High Possibility case
Confirmed VHF case
Moving patient
between wards and
departments
As per standard hospital procedures
Do not transfer unless under direct supervision of ID Consultant/IPCT
PPE
For all contact:
 Standard uniform
 Disposable surgical apron (green)
 Disposable clinical gloves
 Standard footwear (as per dress code)
PPE must cover all exposed skin with sufficient integrity to prevent ingress or seepage
of liquids or airborne particles
If risk of splashing, add:
 Disposable full face visor OR
 Half face fluid shield visor mask OR
 Goggles and fluid repellent surgical face
mask
For all contact:
 Replace uniform with theatre scrubs
 Fluid repellent coverall with hood
 Disposable surgical (green) apron
 FFP3 mask
 Disposable full face visor/face shield
 Double surgical (gauntlet type) gloves (glove to overlap wrist cuff)
 Wellington Boots with over boots
If vomiting/bleeding/bruising present –
adopt PPE as for high possibility case
until VHF screen negative
Aerosol Generating
Procedures (AGPs)
Avoid AGPs unless clinically necessary.
For AGPs in any category of patient: Full PPE as for High Possibility case including FFP3 respirator.
Hand hygiene
As per SICPs
Hand washing with soap and water after removing PPE
Waste
Treat ALL waste as clinical – dispose of into
ORANGE bags (Category B waste)
All waste for incineration – Double YELLOW bags³ (Category A waste)
Sharps waste – YELLOW box & YELLOW lid
Sharps waste – YELLOW box & ORANGE
lid
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Control Measure
Linen
Equipment
Management of Viral Haemorrhagic Fevers
Low possibility case
High Possibility case
Reusable linen- treat any linen visibly
contaminated with blood or body fluids as
disposable (high risk- YELLOW waste bag).
Confirmed VHF case
All reusable linen must be disposed of into YELLOW waste bags
Disposable linen should be considered
If no visible contamination, use alginate bag
& red bag as per SCIPs
*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 (High possibility/confirmed case only) – dispose of into YELLOW waste³
Dedicated commode (if required) – use disposable liner. Solidify all content using granules.
Dispose of content into double YELLOW disposable waste bags³ (DO NOT MACERATE CONTENT)
Cleaning &
decontamination
Toilet/commode: clean with 10,000ppm av. Chlorine after each use
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 coverall, wellington boots, face/eye protection)
Blood: 10,000ppm av. Chlorine (contact time 3 minutes)
Urine: solidify content, dispose of as Category A waste (Yellow bag) – apply 10,000ppm av. Chlorine (contact time 3 minutes).
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Control Measure
Management of
occupational
exposure
Management of Viral Haemorrhagic Fevers
Low possibility case
High Possibility case
Follow SICPS - take immediate steps for First
Aid
Confirmed VHF case
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 temperature
Monitor for bleeding, bruising, diarrhoea
and/or vomiting
If symptoms appear – treat as high
possibility of VHF until VHF screen negative
Stand down
(discontinue
precautions)
If Malaria negative and apyrexial and no other
diagnosis – ID Consultant to discuss with
Imported Fever Service
If Malaria negative and Apyrexial and no
other diagnosis – discuss with Imported
Fever Service
When ID Consultant confirms:
 VHF negative
 Responding to treatment (alternate diagnosis)
 Apyrexial for 24hours
On patient discharge or death.
(ID Consultant to discuss High Possibility cases with Imported Fever Service for other
diagnosis)
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Appendix 4 – Checklist for Consultant Microbiologists when alerted regarding the
possibility of a patient with VHF
CHI number:_________________________
Date:___________________

1. Discussion with Infectious Diseases (ID) Consultant
2. Risk assessment by ID physician:
a. VHF unlikely
b. Low possibility of VHF
c. High possibility of VHF
d. Confirmed VHF




3. Agreement on performing minimum investigations:
a. Blood cultures
b. Malaria film
c. FBC, U&Es, LFTs, clotting, CRP, glucose

4. Inform duty Consultant Haematologist



5. Inform duty Consultant Biochemist

6. Inform Senior Biomedical scientist in Microbiology

7. Ensure all samples are handled in Category 3 containment level and adequate
personal protective equipment is used

8. Arrange VHF screen with Imported Fever Service (08447788990)

9. Inform colleague Consultant Microbiologists at other sites

10. Processing of other samples out with those described above only after discussion
with Consultant ID physician

11. Ensure transport of VHF screen sample is performed in accordance with current
guidance

12. Reference Laboratory result of VHF screen to be telephoned to the ward as soon
as possible

13. Have any samples of blood, urine, stool been already sent inadvertently from the
patient in question:
a. No

b. Yes:

i. Contact the relevant specialty (haematology/biochemistry) and ensure
samples are retrieved appropriately and quarantined, samples must
be disposed in accordance to the SOP
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After results from VHF screen are known, has the patient being confirmed as
Positive

Negative

14. If Negative, inform:
a. Microbiology BMS staff so that precautions can be relaxed
b. Haematology Consultant
c. Biochemistry Consultant



15. If Positive-Confirmed all samples must continue to be processed in Containment
level Category 3
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Appendix 5 - Protocol for Blood Sampling for Patients with Possibility of VHF
Operational Responsibilities
1. To work in conjunction with the Emergency Department (ED) and Infectious
Diseases (ID) Consultant in charge.
2. Ensure safety of other patients and staff.
3. Take and label appropriate specimens as listed below.
4. Ensure safe packaging and transport of these specimens to the laboratory or
laboratories required.
5. The ED or ID consultant must let the microbiology staff know that bloods are
needed to be sent to Porton Down for VHF PCR or not as the case maybe.
Protocol:
1. At Monklands Hospital the ED or ID consultant will contact the Microbiology
Consultant during normal working hours on pager 241 or extension 2117/8. Out of
hours they should contact the On-call Microbiology consultant via switchboard to
alert them that samples from a possible VHF patient will be transported to them.
Name and CHI number of patient should be provided to the Microbiologist
2. The Consultant Biochemist will liaise with the Consultant Microbiologist and/or the
ID Consultant to determine the clinical need of the patient and whether routine
laboratory Biochemist sample analysis is required for the immediate management
of the patient.
3. Please ensure that the BioPack remains in the ante-room and blood samples can
be added to the bubble wrap being held by the buddy. These can then be placed
onto the appropriate labelled box.
4. The Ebola Laboratory kit package should contain all the necessary equipment to
ensure that sampling happens in an organised and safe manner which will include:
a. Selected bottles for ONLY the following samples:
i. Haematology:
1. Citrated pale blue top: Minimum 2ml for clotting
2. EDTA purple top: Minimum 2ml for FBC/malaria
ii. Biochemistry:
1. Yellow top: 5-10ml for U/E, CRP, LFTs & Glucose
iii. Microbiology:
1. Yellow top: 5-10ml for VHF serology
2. EDTA purple top: Minimum 2ml for VHF PCR
3. Blood culture bottles (2)
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5. Check the lids are firmly fixed on all bottles
6. Attach labels to blood sample tubes and blood cultures or handwrite all required
details on all bottles before taking blood.
7. Wear PPE as per protocol following risk assessment.
8. Take Blood using Vacutainer only.
9. Wipe the outside of the tubes with a chlorine based wipe, removing any visible
contamination, and allow to air dry.
10. Blood tubes or blood culture bottles that are visibly contaminated with blood
or are leaking will not be accepted by the laboratory and repeat samples will
be required.
11. Place all sharps into a sharps bin and seal it.
12. Don a new (third pair) of gloves before handling the BioPack packaging and
packing the disinfected blood samples into it
13. Follow the instructions for the use of the BioPack.
14. Do not use pathology transport bag for the samples. Insert these tubes into the
bubble wrap provided in each pack labelled accordingly as biochemistry,
haematology and microbiology.
15. Place each of the blood culture bottles into a clear pathology transport bag and seal
the transport bags and place these samples into the BioJar
16. Screw the top onto the container.
17. Wipe down the outside of the container with alcohol wipes, Chlorox wipes, or a
chlorine based solution
18. Ask the designated person waiting outside the room with the transport box, to open
the door. Insert the jar into the box without touching the box.
19. The laboratory request from should be completed appropriately outside of the
patient’s direct clinical area and inserted outside the jar but inside the box.
20. At Monklands Hospital, the designated person must take the samples to the
Microbiology laboratory on the basement floor. The designated person for the ID
unit is a member of the clinical team. The designated person for the ED is a clinical
support worker.
21. Only hand samples directly to the named individual expecting the samples.
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Appendix 6 – 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
No restrictions or monitoring required
(Category 1)
Low risk
(Category 2)
High risk
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.
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.
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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 Monitoring Officer if temperature >37.5ºC,
with further evaluation as necessary No restrictions
required on accommodation and social contact; HCWs
must not undertake BBV exposure prone-procedures
(EPPs)
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.
Restrictions to be in place for accommodation, social
contact and work
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Appendix 7: WHO (2014) Correct Method of putting on and removing PPE or link to HPS PPE Training Slides
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Appendix 8: Health Facilities Scotland Waste Management Guidance for Highly
Infectious Waste to Accompany HPS Guidance
NHS Lanarkshire
1. The NHS Lanarkshire waste contractor should be notified that highly infectious waste is being
produced or may be produced from a suspected case. Notification can be made by the clinician or
via the Board’s NHS Waste Manager. Contact Harry Campbell NHS Lanarkshire Head of Technical
Services Tel: 01698 377697 Mobile: 07919 396816
2. ‘Soft’ waste should be double bagged in YELLOW clinical waste bags. Bags should then be
placed in a suitably sized rigid container for incineration (burn container). The container should
then be placed in a rigid 770 Ltr UN wheeled container.
3. Any sharps waste should be placed in a regular sharps container (the smallest size needed to
accommodate the amount of waste produced, ensuring the sharps box is not filled more than ¾
full). The container should then be sealed and placed in a suitably sized rigid container for
incineration (burn container). The container should then be placed in a rigid 770 Ltr UN wheeled
container.
4. The outer packaging of highly infectious waste containers must be clearly labelled, the label
must state:
• Waste description: ‘highly infectious waste’;
• The source or point of generation of the waste: ‘room x / ward x’; and
• The date produced.
In the absence of pre-printed labels this information should be handwritten on the external
container.
5. The Contractor should liaise with the site regarding suitable short-term on-site quarantine
storage for highly infectious wastes separate from ALL other wastes. If a quarantine area is not
immediately available waste should be stored in the patient’s room in a safe manner e.g. bagged
and boxed. Quarantine areas for highly infectious waste should be away from areas used to store
other wastes, including other clinical wastes. Where practicable within the quarantine area boxes
containing highly infectious waste should be placed directly into a dedicated 770 litre wheeled
container to avoid double handling of the waste before uplift. Quarantine areas should be locked
to prevent unauthorised access and a record of all waste entering and leaving the area should be
maintained.
6. The timing and frequency of collection must be agreed with the waste contractor at a local level.
Highly infectious waste should not be permitted to accumulate.
7. The contractor is responsible for providing any additional packaging or labelling required prior to
movement off site.
8. The Board will work with the contractor in order to obtain the DfT derogation required to move
this waste in line with the Carriage Regulations 1996 (as amended).
9. In the event that this procedure requires to be activated any associated costs will appear in the
regular monthly invoice, thus no further authorisation should be required from the Board Waste
Management Officer.
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Appendix 9 – VHF Contact Tracing Record
NHS Lanarkshire - SUSPECTED VHF CASE: CONTACT(S) RECORD
(Please complete this form if a suspected case of VHF has been in a common waiting area with other patients/public prior to assessment and/or
isolation)
Case Name:
CHI:
Case Status on Risk Assessment (low/high possibility)
Address:
ED Consultant:
Contact No:
GP:
Hospital:
Patient transport details:
Name of Contact Tracer:
Designation:
Date:
PH contacted:
Y/N
Contact No:
Please fax form to Public Health on 01698 858283 or send it to [email protected] and follow-up with confirmation tel. call on 01698 858232
If you have any queries on completing this form please contact Public Health on 01698 858232
Name
Category of Contact
CHI
(i.e. patient/staff and
specify no/low/high
risk – refer to Section
V, Appendix 6)
Home Address
Telephone No.
Risk Factors /
Vulnerable Group1
E.g. children, pregnant women, immunocompromised, those with comorbidities, health care worker
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* For completion
by Public Health
G.P.
Contact
Informed Informed
1.
1
G.P. Name
And Practice
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Notes/Comments
Management of Viral Haemorrhagic Fevers
Name
Category of Contact
CHI
(i.e. patient/staff and
specify no/low/high
risk – refer to Section
V, Appendix 6)
Home Address
Telephone No.
Risk Factors /
Vulnerable Group1
* For completion
by Public Health
G.P.
Contact
Informed Informed
2.
3.
4.
5.
6.
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Notes/Comments