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The Management of Viral Haemorrhagic Fevers in Ireland
November, 2012
Report of the Scientific Advisory Committee of the Health Protection Surveillance Centre
http://www.hpsc.ie/hpsc/A-Z/Vectorborne/ViralHaemorrhagicFever/Guidance/File,12936,en.pdf
Snip
Table of Contents
The Viral Haemorrhagic Fever Sub‐Committee ...................................................................................... 6
Acknowledgements ................................................................................................................................. 7
Foreword ................................................................................................................................................. 8
Recommendations .................................................................................................................................. 9
Background ........................................................................................................................................... 13
Introduction ...................................................................................................................................... 13
Purpose and Scope ............................................................................................................................ 13
Methods ............................................................................................................................................ 14
1.Introduction ....................................................................................................................................... 17
1.1 What are viral haemorrhagic fevers?.......................................................................................... 17
1.2 The need for new guidance ........................................................................................................ 17
1.3 Overview of VHFs ........................................................................................................................ 18
1.4 Ebola haemorrhagic fever ........................................................................................................... 19
1.5 Lassa fever ................................................................................................................................... 20
1.6 Marburg haemorrhagic fever ...................................................................................................... 20
1.7 Crimean‐Congo haemorrhagic fever ........................................................................................... 21
1.8 Other Old‐World and New‐World Arenaviruses ......................................................................... 23
1.9 Flaviviruses .................................................................................................................................. 23
1.10 Requirement to notify VHF to the World Health Organization under the International Health Regulations, 2005.............................................................................................................................. 26
1.11 Establishment and role of National Isolation Centres .............................................................. 26
1.12 Web resources .......................................................................................................................... 26
2. Clinical Assessment, Risk Categorisation and Initial Management ................................................... 27
2.1 Introduction ................................................................................................................................ 27
2.2 Clinical presentation ................................................................................................................... 27
2.3 Assessment of sick travellers for potential Viral Haemorrhagic Fever ....................................... 30
2.4 Initial management of patient categorised as High Risk ............................................................ 32
2.5 Initial management of patient categorised as At Risk ................................................................ 34
2.6 Patient transfer ........................................................................................................................... 36
2.7 Differential diagnosis .................................................................................................................. 36
2.8 Clinical case management ........................................................................................................... 37
3. Infection Prevention and Control Guidance ..................................................................................... 39
3.1 Introduction ................................................................................................................................ 39 ‐3‐
The Management of Viral Haemorrhagic Fevers in Ireland
3.2 Mode of transmission ................................................................................................................. 39
3.3 Incubation period and infectivity ................................................................................................ 40
3.4 Initial assessment ........................................................................................................................ 41
3.5 Infection prevention and control precautions for managing a patient categorised as At Risk of VHF .................................................................................................................................................... 42
3.6 Infection prevention and control precautions for managing a patient categorised as High Risk of VHF ................................................................................................................................................ 44
3.7 Infection prevention and control precautions for managing a patient with confirmed VHF pending transfer to the NIU, Mater Misericordiae University Hospital ........................................... 49
3.8 Handling human remains ............................................................................................................ 55
4. Laboratory Diagnosis of Viral Haemorrhagic Fever Viruses .............................................................. 57
4.1 Introduction ................................................................................................................................ 57
4.2 Collection of clinical specimens .................................................................................................. 58
4.3 Packaging and transport of biological specimens ....................................................................... 58
4.4 Laboratory testing for At Risk patients ....................................................................................... 59
4.5 Laboratory testing for High Risk patients ................................................................................... 61
4.6 Reporting of results ..................................................................................................................... 62
4.7 Disposal of residual blood samples ............................................................................................. 62
4.8 Contact information .................................................................................................................... 62
5. Public Health Management of Imported VHF ................................................................................... 63
5.1 Irish guidelines ............................................................................................................................ 63
5.2 Notification of a potential case ................................................................................................... 63
5.3 Actions to be taken by the DPH/MOH once notified of a High Risk possible case .................... 64
5.4 Actions by DPH/MOH once case is confirmed ............................................................................ 66
5.5 Preparedness activities ............................................................................................................... 76
6. Transport of Infected Patients .......................................................................................................... 77
6.1 Introduction ................................................................................................................................ 77
6.2 Preparation of the ambulance and crew .................................................................................... 77
6.3 At the pick‐up location ................................................................................................................ 79
6.4 En‐route to hospital .................................................................................................................... 79
6.5 On arrival at the hospital ............................................................................................................ 80
6.6 Decontamination and disinfection .............................................................................................. 80
6.7 Post‐transportation procedures ................................................................................................. 81
7. VHF in the Context of Bioterrorism ................................................................................................... 83
7.1 Introduction ................................................................................................................................ 83 ‐4‐
The Management of Viral Haemorrhagic Fevers in Ireland
7.2 Which VHFs? ............................................................................................................................... 83
7.3 Outbreaks/cases due to deliberate release ................................................................................ 84
7.4 Key medical and public health interventions after identification of a suspected index case of VHF .................................................................................................................................................... 85
7.5 Recommendations for ribavirin therapy in patients with clinically evident VHF of unknown aetiology or secondary to Arenaviruses or bunyaviruses ................................................................. 86
References ............................................................................................................................................ 87
Appendices ............................................................................................................................................ 91
Appendix A: Search Strategies for VHF ................................................................................................. 93
Appendix B: Distribution List for Consultation Document .................................................................... 95
Appendix C: Published Reports on Responses to Imported Cases of VHF ............................................ 97
C.1 Introduction ................................................................................................................................ 97
C.2 Marburg haemorrhagic fever ...................................................................................................... 97
C.3 Lassa fever................................................................................................................................... 99
C.4 Crimean‐Congo haemorrhagic fever ......................................................................................... 104
C.5 Novel Arenavirus infection (Lujo virus) ..................................................................................... 104
References ...................................................................................................................................... 107
Appendix D: Annex 2: Decision Instrument for the Assessment and Notification of Events That May Constitute a Public Health Emergency of International Concern ....................................................... 109
Appendix E: Clinical Risk Assessment Form ........................................................................................ 111
Appendix F: VHF Risk Assessment Algorithm for Use in All Acute Medical Settings .......................... 113
Appendix G: Summary of VHF Risk Categories ................................................................................... 115
Appendix H: Review of Evidence for Mode of Transmission .............................................................. 117
Appendix I: Checklist of Supplies for Acute Hospitals in Preparation for High Risk or Confirmed Cases of VHF .................................................................................................................................................. 125
Appendix J: VHF Risk Assessment for Use by Ambulance Service Personnel at Airports ................... 127
Appendix K: VHF Case Exposure Assessment & Contact Identification Form .................................... 129
Appendix L: VHF Contact Assessment Form ....................................................................................... 139
Appendix M: VHF Contact Surveillance Form ..................................................................................... 145
Appendix N: Case Definitions for Viral Haemorrhagic Fevers ............................................................ 149
Appendix O: VHF Checklists of Actions for Director of Public Health ................................................. 151
Appendix P: Campus Map, Mater Misericordiae University Hospital, Dublin .................................... 155
Glossary of Terms................................................................................................................................ 157
The Management of Viral Haemorrhagic Fevers in Ireland
November, 2012
Report of the Scientific Advisory Committee of the Health Protection Surveillance Centre
http://www.hpsc.ie/hpsc/A-Z/Vectorborne/ViralHaemorrhagicFever/Guidance/File,12936,en.pdf
Snip
Table of Contents
The Viral Haemorrhagic Fever Sub‐Committee ...................................................................................... 6
Acknowledgements ................................................................................................................................. 7
Foreword ................................................................................................................................................. 8
Recommendations .................................................................................................................................. 9
Background ........................................................................................................................................... 13
Introduction ...................................................................................................................................... 13
Purpose and Scope ............................................................................................................................ 13
Methods ............................................................................................................................................ 14
1.Introduction ....................................................................................................................................... 17
1.1 What are viral haemorrhagic fevers?.......................................................................................... 17
1.2 The need for new guidance ........................................................................................................ 17
1.3 Overview of VHFs ........................................................................................................................ 18
1.4 Ebola haemorrhagic fever ........................................................................................................... 19
1.5 Lassa fever ................................................................................................................................... 20
1.6 Marburg haemorrhagic fever ...................................................................................................... 20
1.7 Crimean‐Congo haemorrhagic fever ........................................................................................... 21
1.8 Other Old‐World and New‐World Arenaviruses ......................................................................... 23
1.9 Flaviviruses .................................................................................................................................. 23
1.10 Requirement to notify VHF to the World Health Organization under the International Health Regulations, 2005.............................................................................................................................. 26
1.11 Establishment and role of National Isolation Centres .............................................................. 26
1.12 Web resources .......................................................................................................................... 26
2. Clinical Assessment, Risk Categorisation and Initial Management ................................................... 27
2.1 Introduction ................................................................................................................................ 27
2.2 Clinical presentation ................................................................................................................... 27
2.3 Assessment of sick travellers for potential Viral Haemorrhagic Fever ....................................... 30
2.4 Initial management of patient categorised as High Risk ............................................................ 32
2.5 Initial management of patient categorised as At Risk ................................................................ 34
2.6 Patient transfer ........................................................................................................................... 36
2.7 Differential diagnosis .................................................................................................................. 36
2.8 Clinical case management ........................................................................................................... 37
3. Infection Prevention and Control Guidance ..................................................................................... 39
3.1 Introduction ................................................................................................................................ 39 ‐3‐
The Management of Viral Haemorrhagic Fevers in Ireland
3.2 Mode of transmission ................................................................................................................. 39
3.3 Incubation period and infectivity ................................................................................................ 40
3.4 Initial assessment ........................................................................................................................ 41
3.5 Infection prevention and control precautions for managing a patient categorised as At Risk of VHF .................................................................................................................................................... 42
3.6 Infection prevention and control precautions for managing a patient categorised as High Risk of VHF ................................................................................................................................................ 44
3.7 Infection prevention and control precautions for managing a patient with confirmed VHF pending transfer to the NIU, Mater Misericordiae University Hospital ........................................... 49
3.8 Handling human remains ............................................................................................................ 55
4. Laboratory Diagnosis of Viral Haemorrhagic Fever Viruses .............................................................. 57
4.1 Introduction ................................................................................................................................ 57
4.2 Collection of clinical specimens .................................................................................................. 58
4.3 Packaging and transport of biological specimens ....................................................................... 58
4.4 Laboratory testing for At Risk patients ....................................................................................... 59
4.5 Laboratory testing for High Risk patients ................................................................................... 61
4.6 Reporting of results ..................................................................................................................... 62
4.7 Disposal of residual blood samples ............................................................................................. 62
4.8 Contact information .................................................................................................................... 62
5. Public Health Management of Imported VHF ................................................................................... 63
5.1 Irish guidelines ............................................................................................................................ 63
5.2 Notification of a potential case ................................................................................................... 63
5.3 Actions to be taken by the DPH/MOH once notified of a High Risk possible case .................... 64
5.4 Actions by DPH/MOH once case is confirmed ............................................................................ 66
5.5 Preparedness activities ............................................................................................................... 76
6. Transport of Infected Patients .......................................................................................................... 77
6.1 Introduction ................................................................................................................................ 77
6.2 Preparation of the ambulance and crew .................................................................................... 77
6.3 At the pick‐up location ................................................................................................................ 79
6.4 En‐route to hospital .................................................................................................................... 79
6.5 On arrival at the hospital ............................................................................................................ 80
6.6 Decontamination and disinfection .............................................................................................. 80
6.7 Post‐transportation procedures ................................................................................................. 81
7. VHF in the Context of Bioterrorism ................................................................................................... 83
7.1 Introduction ................................................................................................................................ 83 ‐4‐
The Management of Viral Haemorrhagic Fevers in Ireland
7.2 Which VHFs? ............................................................................................................................... 83
7.3 Outbreaks/cases due to deliberate release ................................................................................ 84
7.4 Key medical and public health interventions after identification of a suspected index case of VHF .................................................................................................................................................... 85
7.5 Recommendations for ribavirin therapy in patients with clinically evident VHF of unknown aetiology or secondary to Arenaviruses or bunyaviruses ................................................................. 86
References ............................................................................................................................................ 87
Appendices ............................................................................................................................................ 91
Appendix A: Search Strategies for VHF ................................................................................................. 93
Appendix B: Distribution List for Consultation Document .................................................................... 95
Appendix C: Published Reports on Responses to Imported Cases of VHF ............................................ 97
C.1 Introduction ................................................................................................................................ 97
C.2 Marburg haemorrhagic fever ...................................................................................................... 97
C.3 Lassa fever................................................................................................................................... 99
C.4 Crimean‐Congo haemorrhagic fever ......................................................................................... 104
C.5 Novel Arenavirus infection (Lujo virus) ..................................................................................... 104
References ...................................................................................................................................... 107
Appendix D: Annex 2: Decision Instrument for the Assessment and Notification of Events That May Constitute a Public Health Emergency of International Concern ....................................................... 109
Appendix E: Clinical Risk Assessment Form ........................................................................................ 111
Appendix F: VHF Risk Assessment Algorithm for Use in All Acute Medical Settings .......................... 113
Appendix G: Summary of VHF Risk Categories ................................................................................... 115
Appendix H: Review of Evidence for Mode of Transmission .............................................................. 117
Appendix I: Checklist of Supplies for Acute Hospitals in Preparation for High Risk or Confirmed Cases of VHF .................................................................................................................................................. 125
Appendix J: VHF Risk Assessment for Use by Ambulance Service Personnel at Airports ................... 127
Appendix K: VHF Case Exposure Assessment & Contact Identification Form .................................... 129
Appendix L: VHF Contact Assessment Form ....................................................................................... 139
Appendix M: VHF Contact Surveillance Form ..................................................................................... 145
Appendix N: Case Definitions for Viral Haemorrhagic Fevers ............................................................ 149
Appendix O: VHF Checklists of Actions for Director of Public Health ................................................. 151
Appendix P: Campus Map, Mater Misericordiae University Hospital, Dublin .................................... 155
Glossary of Terms................................................................................................................................ 157