Sonntag, 08.04. „Er geht euch voraus nach Galiläa" Geplante Flugzeiten Ostergottesdienst zurzeit des Sonnenaufgangs. Folgende Linienflüge mit Lufthansa sind im Rahmen Montag, 02.04. „Zieh weg aus deinem Land" Osterspaziergang zum Wasserfall von En Gedi. Weiterfahrt dieser Reise vorgesehen: Flug von Frankfurt n ach Tel Aviv. Weiterfahrt durch das
of Patients with
Viral Haemorrhagic Fever:
for the Front-line Interim emergency guidance-generic draft for West African adaptation World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER III
IV CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER
[Insert country-specific foreword]
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER V
Table of Contents
Introduction . 1
Principles of VHF management .5
2.1 Case identification/detection .5 2.1.1 History of exposure . 5 2.1.2 Detailed clinical assessment .9 2.1.3 Initial response to a suspected or confirmed case of Ebola/ Marburg, Lassa fever, or CCHF .15 2.1.4 Laboratory investigations and specimen col ection.17 2.2 Notification .21 2.3 Isolation .21 Management of suspected or confirmed cases
of Ebola/Marburg, Lassa fever or CCHF . 23
3.1 Manage symptoms/signs: .24 Fever . 24 Bleeding, severe pallor circulatory shock . 24 Pain . 24 Difficulty breathing/respiratory distress . 24 Vomiting, diar hea, dehydration . 24 Dyspepsia . 25 Convulsions . 25 Signs of hypoglycaemia . 25 Anxiety . 25 Confusion . 25 3.2 Specific therapy for CCHF and Lassa fever .26 3.3 Special considerations in pregnancy .27 3.4 Special considerations for breastfeeding women .28 3.5 Special considerations for children .28 VI TABLE OF CONTENTS
Manage severe confirmed or suspected cases of Ebola/Marburg,
Lassa fever, or CCHF (with emergency signs) . 29
4.1 Shock in VHF patients .29 4.2 Manage septic shock in adults/adolescents . 30 4.3 Manage septic shock in children .34 Management of contacts (exposed individuals) . 41
Psychological support . 43
Infection prevention and control . 45
7.1 Recommendations for direct patient care for known or suspected VHF patients .46 7.2 Standard precautions- at al times, for al patients .48 7.3 Steps to put on and remove essential required PPE .52 7.4 Flow through the isolation ward, for patients and health workers…………………………….57 Discharge . 61
Fol ow up . 63
Case Definitions. 65
Fluid plans A, B and C . 70
Antimalarial, paracetamol and morphine dosing
for children and adults . 73
Clinical monitoring tool . 78
How to give vasopressors . 82
Infection prevention and control – non-direct patient activities. 85
List of abbreviations, acronyms and definition
of some medical terms . 89
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER VII
This manual draws heavily on:
WHO IMAI District Clinician Manual1 WHO Child Pocket Book of Hospital Care for Children2 MSF guidelines for the management of Viral Haemorrhagic WHO Infection Prevention and Control (IPC) guidelines4 Ugandan and MSF experience with running isolation centres and their discharge policies Expert review VIII INTRODUCTION
Viral haemor hagic fever (VHF) is a general term for a severe il ness, sometimes associated with bleeding, that may be caused by a number of viruses. The term is usual y applied to disease caused by: 1. Arenaviridae (Lassa, Lujo, Junin, Guanarito, Sabia and Machupo) 2. Bunyaviridae (Crimean-Congo Haemor hagic Fever - CCHF) 3. Filoviridae (Ebola and Marburg) 4. Flaviviridae (Omsk haemorrhagic fever, Kyasanur forest disease and Alkurma haemorhagic fever) This Guide is focused on specific VHFs-- Ebola, Marburg, CCHF, Lassa fever [and Lujo]-- that occur in Africa and have risk of person to person transmission. This Guide
does not address the management of other viral infections, such as dengue, Rift Val ey
Fever and yel ow fever, that also have haemorrhagic manifestations, but do not have
direct person-to-person transmission.
The purpose of this pocketbook is to provide clear guidance on cur ent best management practices for VHF across health-care facilities.
1. To establish a systematic approach to comprehensive clinical management of VHF cases 2. To build capacity in health workers to use cur ent practices in managing VHFs 3. To build confidence in health workers in managing VHFs through training and skils transfer VHFs are severe and life-threatening viral diseases that are of particular public health importance because they can spread within a hospital set ing, have a high case-fatality rate and are dif icult to recognize and detect rapidly. There is also a lack of ef ective and proven treatment options, apart from supportive care, for Ebola and Marburg. Although ribavirin can be used in Lassa fever and CCHF, the case-fatality rate remains high. The death of health workers is often the first sign that a VHF outbreak has begun, and early CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 1
recognition and implementation of measures to protect health workers is one of the main objectives of early outbreak management. Ebola and Marburg are both Filoviruses with transmission to the index case probably occurring via contact with infected animals, and subsequent transmission via contact with such patient's infected blood and body fluids. The causative agent of CCHF is a Nairovirus, a group of related viruses in the Bunyaviridae family. CCHF is transmit ed via a tick from infected domestic or wild animals (such as deer, cat le, goats, and sheep etc), but it can also be transmit ed by contact with blood or body fluids from infected animals or humans. Lassa and Lujo are in the Arenaviridae family. Humans become infected by exposure to the excreta of its reservoir Mastomys natalensis, also known as the ‘‘multimammate rat.'' Secondary person-to-person transmission of the Lassa virus also occurs through direct contact with infected blood or bodily secretions. Ebola, Marburg and CCHF outbreaks occur periodicaly, but unpredictably. Only one smal outbreak of Lujo has been reported (in Zambia and South Africa). Unlike most VHFs, which are recognized only when outbreaks occur, Lassa fever is endemic in West Africa, with an estimated tens of thousands of cases annual y, with highest incidence in the Kenama and Bo districts of Sierra Leone, but also in Nigeria, Guinea, Liberia and other districts in Sier a Leone. In the 2014 epidemic of Ebola in Guinea, Liberia and Sier a Leone, it is necessary to distinguish between Ebola and Lassa fever by laboratory testing, since only the lat er should be treated with ribavirin. Other than this specific treatment dif erence, the clinical management and infection prevention and control ef orts in health facilities are the same for Ebola, Marburg, Lassa fever and CCHF. VHFs can be encountered at any time and require associated preparedness and planning. While VHF outbreaks begin in the community, patients with VHF ultimately present to their local health facility for care and treatment. In the initial stages of an outbreak (before the outbreak has been recognized), patients with VHF present to their local health facility with a constel ation of symptoms dif icult to dif erentiate from other 2 INTRODUCTION
common infections (e.g., malaria, typhoid, bacterial sepsis). Thus, without maintaining standard infection prevention and control precautions at al time, and a high level of suspicion for VHF in the dif erential diagnosis, health staf and other patients are at risk for acquiring infection. The provision of medical care to critical y il patients can be chal enging in any set ing, particularly resource-limited (including health personnel, medical supplies and equipment) remote environments where VHFs tend to occur. During a VHF outbreak, resource limitations along with the inadequate knowledge and skil s for minimizing the risks of transmission to the health workers can lead to the de-prioritization of patient care. Health workers have an obligation to provide the best medical care to improve patient survival, but also to provide symptom relief and pal iation when required. In the context of patients with VHF, clinical care must be strengthened whilst minimizing the risk of onwards transmission to others, including health workers. Accordingly, it is critical that health workers improve their understanding of VHF and adhere to best practices of infection control at al times (i.e. during and outside of outbreaks). Importantly, inadequate care for VHF patients may also lead to increased reluctance on the part of individuals from the community to identify and isolate possible patients. This downstream ef ect makes case finding through community triage dif icult and can seriously af ect outbreak infection control. The application of appropriate skil s and case management protocols makes the care of a patient with VHF less daunting. The optimal approach depends upon several factors including: a clear understanding of the likely means of transmission in a healthcare environment (and therefore real risks to health workers' trust in the ef icacy of protective measures and prudence in their use; and an approach to patient care that minimizes hazard while maximizing worker safety and ef ectiveness. The purpose of this pocketbook is to provide clear guidance on current best practices for VHF, including both clinical management and infection control and prevention. Throughout this pocket manual, guidance is provided for the front-line health worker focusing on triage and case definition, early and ongoing case management, infection control and subsequent hospital discharge. Recommendations are drawn predominantly from existing published VHF guidelines (primarily consensus-based), and also draw from algorithms for sepsis management from the WHO Integrated Management CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 3
of Adolescent and Adult Il ness (IMAI) and Childhood Il ness (IMCI) guidelines. The rationale for including these sepsis algorithms is that the suspected pathophysiology and final common pathway of severely il patients with VHF is often severe sepsis, with manifestations of increased vascular permeability, vasodilatation, multiple organ failure, and shock. In addition, guidance is provided on infection control and common clinical manifestations of VHF to help the front-line health worker increase his or her level of suspicion for VHF, particularly before an epidemic is recognized in the community. Final y, we provide specific contact information for the front-line provider to facilitate the reporting process to the appropriate public health authorities. Importantly, this document does not cover how to create a VHF treatment unit (i.e. isolation ward), and it also does not address community interventions to control transmission or respond to disease outbreaks. It is hoped that this manual wil be a welcome and complementary addition to such guidance and strengthen the overal response to VHF outbreaks in Africa, fulfil ing the Integrated Disease Surveil ance and Response activities necessary for International Health Regulations compliance. 4 INTRODUCTION
2. Principles of VHF management
2.1 Case identification/detection
The diagnosis of VHF is based on 3 components:
1. History of exposure 2. Detailed clinical assessment 3. Laboratory investigations Health workers should consider VHF in any patient with an unknown etiology as part of the dif erential diagnosis with more common causes of fever in that set ing. Standard case
definitions for VHF have been developed to identify ‘alert', ‘suspect', ‘probable' and
‘confirmed' cases before and during an outbreak (SEE APPENDIX A1 for Ebola/Marburg). Once ‘alert'
cases present to the medical personnel, however, the ‘alert' label should be discarded
and a determination made as to whether the person fal s into the category of a ‘suspect',
‘probable' or ‘confirmed' case. These case definitions may need further refinement to reflect
clinical and epidemiologic features associated with a particular outbreak.
2.1.1 History of exposure to Ebola/Marburg, Lassa fever, or CCHF
One of the most important aids in making the diagnosis is eliciting a history of exposure within 2 to 21 days prior to the patient's onset of symptoms – i.e. within the potential incubation period for Ebola and Marburg. The most common exposure is to blood or any other body fluid (e.g. excreta, vomit, sweat) from a known or suspected Marburg or Ebola case (dead or alive), usual y in providing care or at ending a funeral. Prior to an outbreak being identified, the first clue wil often be a history of exposure to contacts who have been severely ill or who have died suddenly. People typical y most at risk are family members, caretakers, traditional healers, and those participating in traditional burial rituals. Health workers are a recognized high-risk group who should be questioned about recent patient contact and unwel col eagues. Other exposures are: Contact with infected animals, usual y apes and bats, alive or dead, e.g. via CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 5
handling or consumption of infected bush meat, by going into caves (Marburg), or fields close to fruit trees (Ebola) where infected bats roost. Note: the virus is easy to destroy by heating so wel cooked meat is considered virus free. Being breastfed by a woman with Ebola or Marburg is considered an exposure as Ebola virus has been shown to be present in breast-milk.5 As it is unclear how long it remains present, being breastfed by a convalescent patient is also considered a risk. Being the sexual partner of a known or suspected male case, as the virus remains present in semen up to 3 months after clinical recovery. Coming into contact with contaminated items, e.g. medical material, eating utensils, linens from infected patients.5 Note: the virus cannot survive very long in non-organic material, but can be present in material contaminated with body fluids (like needles or other medical material that is reused, dirty bed sheets. ) Receiving healthcare from a provider who is also treating Ebola or Marburg patients and who is not taking appropriate infection control measures.
Community spread mostly occurs through a social network: when
friends and relatives are taking care of a patient or when
participating in funeral activities.
Any acutely il person arriving with the history of such an exposure should be considered a suspect case (see Appendix A case definitions). Unfortunately an exposure history is not always clear (e.g. poor recol ection of interpersonal contacts, reluctance to discuss animal contacts). 6 PRINCIPLES OF VHF MANAGEMENT
History of exposure to Lassa fever
The multimammate rats breed frequently and are a common rodent, most common in rural areas and in dwel ings more often than in the countryside6. Rats infected with the virus shed virus in their excreta. Humans are infected by contact with rats or their excreta or, in some areas, by eating them. The rodent species which carry the virus are found throughout West Africa, so the actual geographic range of the disease may extend to other countries in the region beyond Sierra Leone, Guinea, Liberia and Nigeria. In Sierra Leone, the highest incidence is documented in the dry season. People of al ages are susceptible. Pregnant women are more likely to develop severe disease, especial y in the third trimester. In addition to possible exposure to infected rats at home, other possible modes of exposure include:
Close contacts of a Lassa fever patient within 3 weeks of start of their il ness.
People typical y most at risk are family members, caretakers, traditional healers, and those participating in traditional burial rituals. Receiving health care from a provider who is also treating Lassa patients and who is not taking appropriate infection control measures. Health workers are a recognized high risk group who should be questioned about recent patient contact and unwel col eagues. This group includes both those caring for patients and those testing laboratory specimens from patients in the 3 weeks after the onset of il ness. Being the sexual partner of a known or suspected male case, as the virus remains present in semen up to 3 months after clinical recovery. Coming into contact with contaminated items, e.g. medical material, eating utensils, linens from infected patients. (Note: the virus cannot survive very long in non-organic material, but can be present in material contaminated with body fluids (like needles or other medical material that is reused, dirty bed sheets. ) CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 7
History of exposure to CCHF 7, 8
Farmers, abat oir workers, veterinarians, and health workers are included in the occupational risk groups. Transmission of the CCHF virus can occur to humans in several ways: Bite from an infected tick or crushing a tick against the skin. Ixodid (hard) ticks, especial y those of the genus, Hyalomma, are both a reservoir and a vector for the CCHF virus. Numerous wild and domestic animals, such as cat le, goats, sheep and hares, serve as amplifying hosts for the virus. Contact with the blood of an infected animal. Animal herders, livestock workers, and slaughterhouse workers in endemic areas are at risk of CCHF. Human-to-human transmission through contact with infectious blood or body fluids, in the community or in hospitals. Documented spread of CCHF has also occurred in hospitals due to improper sterilization of medical equipment, re-use of injection needles, and contamination of medical supplies Possible horizontal transmission from a mother to child has been reported. The risk of exposure during breast feeding, however, is unclear9 8 PRINCIPLES OF VHF MANAGEMENT
2.1.2 Detailed clinical assessment
Common clinical features of Ebola, Marburg, Lassa fever and CCHF infections
The initial clinical manifestations of Ebola, Marburg, Lassa fever and CCHF infections are non-specific and mimic many common infections making them dif icult to diagnose early. Thus, it is important to understand the case definition and expand your dif erential diagnosis to include other causes of fever and non-specific symptoms (e.g., malaria, typhoid, upper respiratory infections and urinary tract infections). Also, despite being cal ed a viral haemor hagic fever, the clinical presentation of VHF only includes haemor hage in less than half of confirmed Ebola/Marburg cases and less than 20% in confirmed Lassa cases. It is critical that health workers make themselves aware of other common signs and symptoms of VHF, to al ow early identification of VHF cases that do not include haemorrhage. In addition, while there is distinction between early and late clinical signs of VHF, it is important to remember that patients may present at dif erent times in the course of their il ness. Severity of il ness may depend on a number of factors including the body's natural immune response, mode of transmission, duration of exposure, infecting dose, phase of il ness of the case, and possibly even the virus strain. Thus, front-line health workers should have a high level of suspicion for VHF in patients who fol ow the case definitions, even when their clinical presentation is mild. Clinical features of Ebola/Marburg 10,11
The Ebola and Marburg viruses are both part of the family of Filoviridae. The incubation period for these viruses (i.e., the period when the patient remains asymptomatic after exposure to a contact) can range from 2 to 21 days. Marburg is typical y 5-9 days and Ebola 3-12 days. Ebola and Marburg virus diseases usual y begin with a flu-like syndrome with fever and profound weakness, often accompanied by arthralgia, myalgia, headache, anorexia and hiccups. These are usual y fol owed by gastrointestinal symptoms: nausea, vomiting, and diarrhea. Patients may also complain of dysphagia. See Table 2. Despite a common belief that haemor hage is a defining feature of filovirus disease, visible bleeding is not universal. When present, bleeding is not an early presenting feature, but often only appears in the later stages of filovirus disease. It may CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 9
manifest as overt bleeding or a combination of major and minor bleeding signs, but is frequently only minimal and sometimes solely internal (and therefore frequently missed). Clinical features of Lassa fever
The incubation period is 6-21 days. Clinical distinction between VHFs is dif icult, emphasizing the importance of prompt laboratory testing to identify Lassa fever early enough for ribavirin to be ef ective. Swol en face and neck are classic signs in Lassa fever but only occur in about 10% of cases; these are not seen in Ebola/Marburg. Sore throat occurs in both but exudative pharyngitis and convalescent hearing loss suggest Lassa fever. Tenderness over the liver suggests Ebola/Marburg. Only about 20% of Lassa fever patients develop haemor hage, as opposed to 50 to 60% of Ebola (depending on the subtype). Lassa fever typical y has a more indolent presentation with patients feeling fatigued and "feverish" for a few days, whereas significant il ness in Ebola/Marburg begins more abruptly and evolves more rapidly. Lassa fever is mild or has no observable symptoms in about 80% of people infected and unapparent infection, diagnosed serological y, is common in endemic areas. Because of these frequent mild infections, the overal case fatality rate can be quite low; hospital studies in symptomatic patients report the case fatality rate as 15 to 25%12,13. Severe multisystem disease is seen in a subset of patients, however, and in the case of some epidemics, the mortality has been reported as high as 80%.There may be viral strain dif erences between Lassa fever in Nigeria and Sier a Leone. Moreover, disease seems to be more severe in pregnancy with frequent maternal mortality, particularly in the third trimester, and 80% fetal loss. The virus is excreted in urine for 3 – 9 weeks after infection and in semen for 3 months14. The extent of sexual transmission is unknown. 10 PRINCIPLES OF VHF MANAGEMENT
Clinical stages of severe Lassa fever (adapted from McCarthy 200215)
General weakness and malaise. High fever, >39°C, constant with peaks of 40-41°C Sore throat (with white exudative patches) very common Headache; back, chest, side, or abdominal pain Conjunctivitis Nausea and vomiting Diarrhoea Productive cough Proteinuria Low blood pressure (systolic <100 mm Hg) Oedema of the face and neck Convulsions Mucosal bleeding (mouth, nose, eyes) Internal bleeding Encephalopathy with confusion or disorientation During convalescence, transient alopecia and ataxia may occur. Sensorineural hearing deficit (eighth cranial nerve) is common (29% of confirmed cases compared with none of febrile controls in hospital inpatients)16, with no relationship to severity of viral il ness. Only about half recover some function. Laboratory features include early lymphopenia which may be may be fol owed by late neutrophilia. Platelet counts are moderately depressed, and platelet function is abnormal. Aspartate amino-transferase (AST) levels above 150 and high viremia are poor prognosis indicators for the patient. Severe disease may be accompanied by albuminuria and hemoconcentration. Clinical features of Crimean-Congo Haemorrhagic Fever17, 18, 19, 20
For CCHF, the incubation period depends on the mode of acquisition, but is usual y 3-7 days. The documented maximum after a tick bite is reported as 9 days and after CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 11
contact with infected blood or tissues 13 days. The clinical characteristics of patients with CCHF infection present a wide spectrum of disease severity from mild to fatal outcome (case fatality rate 5–30%). The onset of CCHF is sudden, with initial signs and symptoms including headache, high fever, back pain, joint pain, abdominal pain, and vomiting. Red eyes, flushed face, red throat, and petechiae (red spots) on the palate are common. Symptoms may also include jaundice, and in severe cases, changes in mood and sensory perception. The haemor hagic period is short (usual y 2–3 days, but up to 2 weeks), develops rapidly, and usual y begins between the third to fifth days of disease. Haemor hagic manifestations of CCHF are common and range from petechiae to large haematomas appearing on the mucous membranes and skin. The most common bleeding sites are the nose (epistaxis), gastrointestinal system (haematemesis, melena, and intra- abdominal bleeding), uterus (menor hagia–excessive menstrual bleeding; other vaginal bleeding), urinary tract (haematuria), and the respiratory tract (haemoptysis). Uncontrol ed bleeding at injection sites can also be seen and bleeding from other sites, including cerebral haemor hage have been reported. In approximately 30% of the patients, hepato-splenomegaly can also be found. Laboratory features of CCHF are thrombocytopenia, leukopenia, elevated liver enzymes, and prolonged bleeding times. Laboratory tests return to normal levels within approximately 5–9 days among surviving patients. Most of the early clinical signs of CCHF are non-specific and can also be seen with Ebola/Marburg and Lassa fever, so dif erentiation often relies on exposure history and laboratory testing. Any acute il ness, especial y febrile il ness, not clearly due to a
common pathogen or which is unresponsive to initial empirical
therapy, should raise concern for VHF. This is especial y true if there
is unexplained bleeding or rapid deterioration of the patient's
12 PRINCIPLES OF VHF MANAGEMENT
Early and late clinical features of Ebola/Marburg infection
Early clinical features of Ebola/Marbu
• Intense tiredness, weakness, malaise • Conjunctivitis • Sudden onset of fever (defined as • Nausea and loss of appetite 38.0˚C axilary)* • Throat pain and dif iculty swalowing • Abdominal pain • Myalgia (muscle pain) • Diar hoea (can be bloody • Arthralgia (joint pain) • Hiccups Note: There is often an overlap of early and late symptoms. Patients often do not develop all the signs and symptoms. CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 13
Late clinical features
• Confusion and ir itability
• Chest pain
• Diar hoea (watery or bloody)
• Vomiting (sometimes bloody)
• Skin rash
• Internal and/or external bleeding including:
- oozing from puncture sites - epistaxis (bleeding from the nose) - rashes suggestive of easy bleeding - haematemesis (blood in vomitus) (e.g., ecchymoses, petechiae, - haemoptysis (blood in sputum) purpura) - dark blood in stool (melena, hematochezia) - bleeding from the gums - unexplained vaginal bleeding in - conjunctival haemor hage (bleeding from the eyes) - haematuria (blood in urine) • Miscar iage in pregnant woman** • Shock (see definition • Respiratory distress of shock in section 4) *Fever may be absent in late stages ** Pregnant patients with VHF often miscar y. However, vaginal bleeding and miscar iage can occur in any pregnancy. During an Ebola/Marburg or CCHF outbreak, fever with miscar iage or abnormal vaginal bleeding (other than normal menstruation) should prompt a PCR test to rule out VHF. 14 PRINCIPLES OF VHF MANAGEMENT
2.1.3 Initial response to a suspected or confirmed case of
Ebola/Marburg, Lassa fever or CCHF21
Initial procedures for evaluation and response to al patients
presenting to health centre or hospital in a VHF-prone area
• Perform the Quick Check (in adolescents or adults ETAT in young childre• Review the patient history: - Any contact with someone in the previous 3 weeks who was ill with fever +/- bleeding or who died from an unexplained il ness with fever +/- bleeding? - Any contact with other family members who are sick or have died from a disease with similar symptoms and signs? - Unexplained death of wild animals in the area? - History of contact with blood and body fluids of wild animals (especial y monkeys, bats, rats, etc.)? - History of visiting/exploring caves or working in mines infested with bats? - Received a tick bite or crushed a tick with their bare hands? - Home infested with rats? 2. If you suspect a case of VHF
• Cal for help from doctor within the facility for further evaluation • After further evaluation, contact the hospital/district surveil ance focal person and/or District Health Officer • Keep the patient in the holding room/area CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 15
2. Educate the patient if conscious and cooperative
• Educate the patient on what wil happen next • Explain the reasons for the isolation/holding • Explain the procedures you are fol owing with respect to control ing transmission to the family, health workers and the community • Educate the patient on respiratory hygiene • Give the patient a surgical mask and make sure he/she understands how to use it 3. Isolate the patient
• Triage rapidly to a separate room /holding area • The holding area should be: - Distant from other crowded areas - Wel ventilated - Have adequate sunlight - Known to everyone in the facility 4. Notify/Refer the patient
• Make every effort to reduce the waiting time between initial y seeing the patient and notification/refer al • Develop a system to move patients quickly and reduce the time that others are exposed Summary of what to do when you suspect VHF
• Use standard precautions and use available personal protective equipment before examining the patient(s) • Isolate the patient • Notify the district health officer (DHO) immediately using the most urgent available means (telephone, message, etc). The DHO wil send the rapid response team to investigate the event further. (Refer to IDSR Guidelines22 for details) • Where possible, take off blood samples to diagnose VHF (see Section 2.1.4) and send them to the appropriate laboratory 16 PRINCIPLES OF VHF MANAGEMENT
2.1.4 Laboratory investigations & specimen col ection
All samples should be considered as highly infectious. Early recognition of VHF depends on a high index of clinical suspicion by the at ending health worker. The ability to confirm the diagnosis of VHF also requires highly specialized reference laboratories. In West Africa, these are located in … [please insert relevant reference labs to send samples for suspected VHF] Laboratory personnel (technician level or above) who have been trained in shipment of highly infectious biological substances and in safe blood sampling, and also trained on how to put PPE on and of , should ensure the fol owing procedures are fol owed for investigations: 1. Ensure al specimen col ection containers are available (SEE TABLE 4).
2. Col ect samples taking necessary protective precautions and ensure samples are
appropriately labeled, including unique patient identifiers (name, DOB). 3. Package samples according to standard guidelines. 4. Send the samples immediately to the appropriate reference laboratory marked urgent. There may be a country wide network of laboratories where samples for transportation to the national reference laboratory (or laboratory in a neighboring country) are gathered. Usual y the regional centres have means to pick samples from lower health units within their prescribed areas of operation, where they are ultimately picked and dispatched to the appropriate laboratory. 5. If packaging materials are not available keep the sample in a refrigerator or in a freezer at -20º C or colder. Consider other causes of fever in your dif erential diagnosis and if available exclude through appropriate investigations. Refer to the IMAI District Clinician Manual dif erential diagnosis tables for adultnd to the Child Pocket Book for childre CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 17
Interpretation of VHF laboratory results from acute
Lab confirmation of:
PCR and/or IgM positive Recent infection (within previous couple of IgM and IgG positive months, i.e. in cur ent outbreak) Older infection (within the last couple of High IgG positive only (no IgM) years) Past infection (not associated with Lower IgG positive only (no IgM) cur ent outbreak) ***If a specific diagnosis in additon to VHF is made (e.g. pneumonia), use established principles and guidelines for treating those conditions. It is important that identifying the source of infection should not delay delivery of supportive treatments and empirical antibiotics Malaria testing
Always test for malaria with a rapid diagnostic test (RDT) at the bed side taking necessary precautions. If a RDT or malaria smear is negative, the patient does not have malaria. It is dangerous to at ribute fever to malaria when it is not present because the patient does not get the right case management if they are incorrectly diagnosed as having malaria. If the malaria test is positive but the patient is considered to be a suspected case during a Filovirus, Lassa fever or CCHF outbreak, or at any time in a Lassa endemic area, await confirmation from Filovirus, Lassa fever and/or CCHF virus testing (or response to anti-malarial treatment) before discharging the patient from the isolation ward. 18 PRINCIPLES OF VHF MANAGEMENT
Specimen col ection for viral haemorraghic fevers
For ELISA: Whole blood, serum or plasma For PCR: Whole blood or blood clot, serum/plasma or tissue For immunohistochemistry: Skin or tissue specimens from fatal cases. When and how
Collect specimen from the first suspected case. to collect
If more than one suspected case, collect specimens from every suspected
All specimens should be regarded as potentially infectious, and health workers
who collect or transport clinical specimens should adhere rigorously to
(SEE SECTION 7) to minimize the possibility of exposure to pathogens.
How to prepare,
HANDLE AND TRANSPORT SPECIMENS FROM SUSPECTED VHF
PATIENTS WITH EXTREME CAUTION. WEAR PROTECTIVE CLOTHING AND
USE BARRIER PRECAUTIONS.
For ELISA or PCR:
Refrigerate serum or clot
Freeze (-20º C or colder) tissue specimens for virus isolation
Fix skin snip specimen in formalin. Specimen can be stored up to 6 weeks.
The specimen is not infectious once it is in formalin. Store at room
temperature. Formalin-fixed specimens may be transported at room
ALL SPECIMENS MUST BE PACKAGED USING TRIPLE PACKAGING
SPECIMENS MUST BE APPROPRIATELY LABELLED AND
ACCOMPANIED WITH COMPLETE DOCUMENTATION (INCLUDING CASE
Diagnostic services for VHF are not routinely available. Advance arrangements are required for VHF diagnostic services. Contact reference laboratory for immediate at ention. After the sample ar ives, a result will be available within 24 hours CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 19
Due to the potential risk of transmission to laboratory workers, additional blood tests are not to be sent to the routine laboratory until the results of the VHF screen are known and negative. An exception to this is the use of RDT for malaria and other point of care equipment (such as the i-STAT® System) by appropriately trained personnel. The lat er, however, is unlikely to be available until an outbreak is declared and additional support is provided. Laboratory diagnosis of Ebola/Marburg, Lassa fever or CCHF
Laboratory diagnosis can be dif icult depending on the phase/time of presentation, duration of symptoms and previous exposure. The ability to confirm the diagnosis of VHF also requires highly specialized (with high biosafety infrastructure) reference laboratories that are central y located. If blood tests have been performed, the fol owing laboratory findings (in combination with the clinical presentation) are suggestive of VHF but not conclusive: thrombocytopenia; elevated hematocrit; and marked leukopenia. To confirm a VHF case, three laboratory tests can be run on blood samples (blood, serum or plasma) col ected in patients suspected of having VHF, depending on the time of sample col ection relative to the date of disease onset. 1) Polymerase chain reaction (PCR) provides evidence of the virus in the blood or tissues during the acute phase of the clinical disease. In certain circumstances, this test can be replaced by an antigen detection ELISA (it is less sensitive and more broadly cross- reactive); 2) IgM (antibody showing recent infection) during the early convalescence phase of disease (until approximately 8-12 weeks post onset of disease) 3) IgG (antibody showing past infection) persists for several months/ years after the acute phase of the clinical disease. This alone is not suggestive of recent or ongoing infection but can be utilized to confirm acute infection with paired samples showing IgG seroconversion. The levels of virus increase during the first days of symptoms and this increase cor elates with the patient's degree of infectiousness. Viral levels are both dependent on the patient's immune response and the amount of infecting dose. If the patient produces a good immune response to the virus, antibodies (IgM and IgG) wil start to be produced 20 PRINCIPLES OF VHF MANAGEMENT
and can be measured. Conversely, a weak immune response to the virus cor elates with high levels of virus in the blood and is associated with a high mortality. For patients who have died, immunohistochemistry testing has also been used to detect some VHF (e.g., Ebola or Marburg) from post-mortem skin necropsy. All samples for clinical laboratory tests from patients with possible VHF should be considered very infectious and processed accordingly (i.e. not sent to routine laboratories). Essential investigations should be undertaken and laboratory staf informed. Pitfalls in laboratory results interpretation
Sensitivity is increased by use of paired samples separated by at least 3 days.
False negative results are likely to occur in samples taken in early phases of the
New VHF strains/virus can occur (e.g., Lujo virus)
IgG alone is not diagnostic of acute or recent infection except if evaluating rising
titres in paired samples. Cross-reaction of IgG/IgM with other pathogens is possible. 2.2 Notification
Once VHF is suspected, immediate notification to the next level and district should be done using the appropriate and quickest available means, especial y telephone and other modalities such as mTRAC. The event also needs documentation using the appropriate reporting form (HMIS 033a). All subsequent suspected cases should be reported and recorded on a line list for further action (refer to the IDSR 2010 guidelineor details). 2.3 Isolation
One of the key guiding principles in the management of VHFs is the triaging of cases and ensuring isolation of suspected and confirmed cases to mitigate further spread of disease. Ideal y an isolation area should already be available to admit patients requiring isolation. If an isolation area is not available or if advance preparations have not been done, and VHF is suspected, immediately identify and set aside a single room. This room should have an adjoining toilet or latrine, good ventilation, screened windows and restricted access. Details on how to set up the isolation unit as part of the VHF treatment centre are explained elsewhere. CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 21
22 PRINCIPLES OF VHF MANAGEMENT
3. Management of suspected and confirmed Ebola, Marburg,
Lassa fever or CCHF cases
The clinical management of VHF is predominantly supportive and should focus on early recognition of severe disease and complications, in combination with appropriate
symptom management. The level of care and interventions required varies across the
spectrum of disease severity, including complex management of septic shock and
pal iation when indicated. Control of pain and management of anxiety are particularly
important and al patients need careful monitoring, as wel as psychological support (see
Health workers should pay careful at ention to standard precautions and wear PPE (see section 7) while providing careful clinical care.
Always start each patient assessment with the Quick Check (in adolescents and adults) or the ETAT (in children) for emergency signs and respond with emergency treatments. The wal charts for these should be posted in the isolation wards. The IMAI District Clinician ManuIMAI DCM) and the Pocket Book of Hospital Care for Childreshould be available for consultation for further details on care. CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 23
3.1 Manage symptoms/signs
Specific management of signs and symptoms
Fever (>38.0 °C)
Manage fever with paracetamol (see Appendix C for dosing). Avoid diclofenac, ibuprofen or aspirin due to platelet effects. Further details in IMAI DCM: Section 10.1; in Child pocket book p. 305 Acute significant bleeding/
Transfuse with whole blood moderate to severe pallor/
Further details in IMAI DCM: Section 10.18; in Child pocket book pages 161, 218, 308-312. emergency signs of circulatory
Treat pain with paracetamol (if mild) or morphine (if moderate and severe). Avoid diclofenac, ibuprofen or other NSAIDs due to platelet effects. Paracetamol and morphine doses are in Appendix C. Further details in IMAI DCM: Section 20; in Child pocket book Section 10.4, p. 306 Dif iculty breathing/ respiratory
Oxygen: titrate to Sp02 ≥90% distress
If SpO2 < 90%, start adult on 5 litres/minute (nasal prongs); start child at 1-2 litres/minute (nasal prongs) Evaluate for pneumonia, wheezing, fluid overload, congestive heart failure and manage accordingly. (Do not share nasal prongs -once used by a patient, dispose.) Further details in IMAI DCM: See Section 3.2 for management respiratory distress, CHF, and pneumonia; in Child pocket book Pages 11,82,312-315 Diarrhoea, vomiting, signs of
Provide ORS even if no signs of dehydration Monitor signs of dehydration. If no, some or dehydration
severe dehydration, use Fluid Plans A, B and C, respectively (see Appendix B and, for children, see p. 34 below). If severely malnourished child with shock, see p. 35 below. Nausea and vomiting are common- anti-emetic medications may provide some relief and facilitate oral rehydration. For adult, give chlorpromazine 25-50 mg, 4 times daily IM or oraly or metoclopramide 10 mg IV/ oraly 3 times daily until vomiting stops. For children, give promethazine. Monitor for extrapyramidal signs. Further details in IMAI DCM Sections 10.7c and 10.7d; in Child pocket book Section 5. 24 MANAGEMENT OF SUSPECTED OR CONFIRMED CASES OF EBOLA/MARBURG OR CCHF
Specific management of signs and symptoms continued
In adults and children ≥ 10 years, give omeprazole 20 mg orally daily or (i.e., "heartburn")
magnesium trisilicate, 2 tabs every 8 hours until symptoms resolved. In children 5-12 years, give magnesium trisilicate: 5-10 mls, 3 times daily Further details in IMAI DCM: Section 10.7c Convulsions
Approach convulsing patients with caution. Give diazepam to abort seizure if prolonged (rectaly if there is not an IV already in place- adult 20 mg (4 ml of 10 mg/2ml solution); child 0.5 mg/kg) , then control with phenobarbital loading dose (child: 15 mg/kg over 15 minutes- IM or IV); adult:10 mg/kg. Further details in IMAI DCM: Quick Check page 42; ETAT page 15 Signs of hypoglycaemia
Test glucose (and monitor regularly) If low, give IV D50 5 ml/kg in child; 25 to 50 ml of D50 in adult Nutritional support Further details in IMAI DCM: Quick Check page 42; in Child pocket book page 16 Psychological support (see section 6 of this manual) Diazepam – adults: 5-15 mg/day in 3 divided doses Further details in IMAI DCM: Section 10.11 Confusion in cooperative patient
Reason with patient in calm and non-aggressive fashion. Keep lighting on at night. Consider diazepam 5 mg at night (adult) Confusion and aggression in
Give sedation-haloperidol 5 mg IM (adult) non-cooperative patient
Further details in IMAI DCM: Quick Check page 60 See diagnosis and management of septic shock below. Further details in IMAI DCM: Section 3.1 3.2 Specific therapy for Lassa fever and CCHF
Ribavirin can be used to treat patients with Lassa fever and CCHF and also considered for high-risk Lassa fever and CCHF patient contacts. Ribavirin is not used in Ebola or Marburg disease for which it has no activity. Its ef icacy in CCHF and Lassa CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 25
fever has not been proven by a randomized control ed trial, and there are dif erences in opinion on its clinical ef ectiveness in the published literature. Nevertheless, observational data from Lassa fever, for which there has been more experience, suggest that ribavirin is most ef ective if given in the first 6 days of il ne Ribavirin dose for treatment of Lassa fever and CCHRoute
Loading dose fol owed by: (maximum 2 grams)** Every 6 hours for 4 days, (maximum 1 gram)** Every 8 hours for 6 days. (maximum 500 mg)** * Dilute ribavirin in 150 ml of 0.9% saline and infuse slowly. ** Reduce the dose in persons known to have renal insuf iciency (creatinine clearance < 50 ml/minute). Major adverse ef ects due to short-term ribavirin therapy are rare but require monitoring. The main side-ef ect is a dose-dependent, mild-to-moderate haemolytic anaemia that infrequently necessitates transfusion and disappears with cessation of treatment. Rigors may occur when ribavirin is infused too rapidly. Relative contraindications include severe anaemia or haemoglobinopathy, coronary artery disease, renal insuf iciency, decompensated liver disease, breast-feeding and known hypersensitivity. Jaundice may develop in patients with Gilbert's syndrome. Haemoglobin/haematocrit and bilirubin levels should be checked at initiation of ribavirin therapy and then every few days, with consideration of transfusion of packed red blood cel s if significant anaemia develops. Because of the long terminal half-life ( 24 hours) and large volume of distribution, ribavirin may stil have ef ect for hours or even days after cessation, particularly in red blood cel s where it accumulates. Although findings of teratogenicity and fetal loss in laboratory animals have rendered ribavirin technical y contraindicated in pregnancy, its use must stil be considered as a lifesaving measure given the extremely high maternal and fetal mortality associated with Lassa in pregnancPatients who have had ribavirin should refrain from unprotected sex for up to 6 months after exposure. 26 MANAGEMENT OF SUSPECTED OR CONFIRMED CASES OF EBOLA/MARBURG OR CCHF
Both progressive hemolytic anemia and hypomagnesemia have been shown to be dose-dependent23. Bradycardia has also been reported. Other non-specific complaints associated with ribavirin include headache, fatigue, insomnia, and nausea. Oral formulations should be restricted to post-exposure prophylaxis for high-risk exposures to Lassa fever and CCHF (see Section 5). For children, the use of oral or intravenous ribavirin has not been approved. 3.3 Special considerations in pregnancy
Ful term deliveries are rare in Ebola/Marburg. Fetal death occurs in 80% of pregnant Lassa fever patients. Basic facilities for deliveries and a private area to manage miscarriage and vaginal bleeding should be instal ed. Extreme caution must be used during management of bleeding to avoid health worker infection. There are reports of clinical improvement in pregnant women with Lassa fever after the uterus is evacuated.24 As uterine evacuation in pregnant patients appears to lower maternal mortality, it should be considered in confirmed cases given the extremely high maternal and fetal mortality. However, this high-risk procedure must be performed with extreme caution, given potential for nosocomial transmission and the risk for inducing maternal haemorrhag Fol ow clinical guidelines for use of ergometrine in early pregnancy and oxytocin and other interventions post-partum to stop bleeding. 3.4 Special considerations in breastfeeding women
Ebola and Marburg viruses have been found in breast milk. During a Marburg outbreak in Angola in 2005 there was a high number of paediatric cases, and breastfeeding may have been a factor in Marburg virus transmission as indicated by the epidemiology and Marburg virus- positive breast-milk specimens25. Given the potential risk of transmission through breastfeeding, a woman who has CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 27
been admit ed as a suspect Ebola, Marburg, Lassa fever or CCHF patient may have already infected her breastfed infant. The infant should also be admit ed and isolated. Do not send breastfed infants home that may be infected and who could soon be Default advice is to STOP breastfeeding, but this should be in context with an individual risk assessment on the likelihood of VHF, and the ability to provide alternative feeding to the infant. If the mother is conscious, help her express her breast milk manual y, continue stimulation of milk production, and relieve breast congestion. If she is unconscious, a health worker trained on breastfeeding expression may help the mother extract breast milk. Given the risk of splashes, the person helping with milk expression should use gloves, a gown and face protection. - Safely prepared commercial infant formula milk should be given to infants under 6 months. Give training on the safe preparation, storage and use of artificial milk to the staf . If the infant is older than six months, cow's (or other animal) milk and adequate complementary foods are suf icient - Discourage wet-nursing; if the baby breastfeeds from another woman, there is a theoretical risk that the baby wil transmit infection to this woman, given the close contact during breastfeeding. The mother may require psychological support. 3.5 Special considerations for children
If the child becomes sick and both the mother and child test positive for Ebola or Marburg disease, then the child can be returned to the mother. If the child is negative (and it may be prudent to carry out two tests two days apart), he/she can leave pediatric isolation and be fol owed closely as a high-risk contact if there is a family member who can care for the child safely at home, while discouraging wet-nursing. 28 MANAGEMENT OF SUSPECTED OR CONFIRMED CASES OF EBOLA/MARBURG OR CCHF
4. Manage severe confirmed or suspected cases of
Ebola/ Marburg, Lassa fever, or CCHF (with
4.1 Shock in VHF patients
General signs of shock (poor perfusion) Low BP (SBP <90) Fast weak pulse Pal or or cold extremities Decreased capil ary refil Dizziness or inability to stand Decreased urine output (<30 ml/hour) Difficulty breathing Impaired consciousness, lethargy, agitation, confusion. Note: Assessment of pulse and BP should be taken in the context of the patient's pre- morbid state, pregnancy, age, and medication. Some pregnant women, patients with chronic il ness, and others may normal y have a SBP <90 mmHg and have normal mental status, capil ary refil , and urine output; they do not have shock. VHF patients can be in shock from haemor hage or from septic shock. The pathophysiology and the intensive supportive care for VHF are the same for septic shock from a bacterial infection, malaria and other causes of septic shock26, 27. Intensive supportive care is the only clinical management that can be provided to these patients and may have a positive impact on disease outcome. VHF patients may also have co-infection with bacteria or malaria that can contribute to septic shock. It should also be recognized that VHF patients can also develop hypovolaemic shock as a result of haemor hage. The shock in a VHF patient may be a combined picture from haemor hage, disseminated intravascular coagulation (DIC) and from sepsis. MANAGEMENT OF SUSPECTED AND CONFIRMED EBOLA, MARBURG OR CCHF CASES 29
Cal for help from the most experienced clinician available when a VHF patient 4.2 Manage septic shock in adolescents and adults
CLINICAL DIAGNOSIS of severe sepsis or septic shock:
Suspected infection plus
Hypotension (systolic blood pressure <90 mmHg) plus
One or more of the fol owing:
Pulse >100 per minute
Respiratory rate >24 breaths per minute
Abnormal temperature (<36º C or >38º C).
Use the flowchart on the fol owing pages for specific guidance on the management of
septic shock. It is arranged by hours, starting from patient arrival or time septic shock is diagnosed and uses a systematic approach for the recognition of problems, giving oxygen and fluids, and how to monitor, record, and respond to findings. These basic General principles of managing patients with septic shock
• Manage airway (see Quick Check). • Give oxygen (see Quick Check). • Give IV fluid rapidly (see specific fluid recommendations which fol ow). • Treat underlying cause. • Consider vasopressors if SBP <90 and signs of inadequate perfusion after fluid resuscitation. • Monitor – record – respond. recommendations provide guidance on intensive supportive care for patients with shock of most aetiologies, including VHF. Below is more detailed information about these basic interventions. 30 MANAGEMENT OF SEVERE CONFIRMED OR SUSPECTED CASES OF EBOLA/MARBURG OR CCHF
Give fluids rapidly
First give an initial 1000 ml LR or NS bolus, continue Ringer's lactate (LR) or Normal saline (NS) at 20 ml/kg/hour, not to exceed a maximum of 60 ml/kg in the first 2 hours (including the initial bolus). Monitor systolic blood pressure (SBP) and clinical signs of perfusion (urine output, mental status). If SBP remains <90 and signs of poor perfusion continue after fluid resuscitation over the first 2 hours, Consider adding vasopressors (dopamine or epinephrine) using the instructions in Appendix D (How to give vasopressors). To avoid fluid overload, decrease the rate of fluids to 5–10 ml/kg/hour. At 2–6 hours, if SBP rises above 90, continue fluids at 2 ml/kg/hour. However, if the pulse is stil high and there are other signs of poor perfusion, patient may stil be volume-depleted and need more fluids. Watch careful y for signs of fluid overload (increased jugular venous pressure, increasing crepitations on auscultation). If present, decrease the rate of fluid administration. Cal for help from more senior clinician to further evaluate overload and decide fluids. Give empirical IV antimicrobials within the first hour.
Antibiotics: Urgently administer broad spectrum antibiotics by IV. Take blood cultures before antibiotics, but do not delay treatment to get blood cultures. Choice of antibiotics depends on presence of signs of local infection, local disease pat erns, and availability of antibiotics. A good choice is ceftriaxone 2 grams daily IV. If community-acquired pneumonia is suspected, refer to your national or institutional guidelines. MANAGEMENT OF SUSPECTED AND CONFIRMED EBOLA, MARBURG OR CCHF CASES 31
Management of septic shock in adults and adolescents
Manage Septic Shock: First 2 hours
Clinical diagnosis of severe sepsis or septic shock
Reconsider other causes of shock if no change in Suspected infection. SBP fol owing fluid boluses. Hypotension (systolic blood pressure <90 mmHg) and 1 or more of the Consider internal haemorrhage. Pulse >100 beats per minute (bpm). Establish any additional source of infection. Respiratory rate >24. Abnormal temperature (<36°C or >38°C). Oxygen: titrate to SpO2 90.
Oxygen: Titrate to SpO2 90.
After initial bolus of 1000 ml, continue rapid fluids If SBP >90, continue fluids at 2 ml/kg/hour. LR or NS at 20 ml/kg/hour, up to 60 ml/kg within the first 2 hours. If SBP <90 at 2 hours or later, start vasopressors and continue fluids at 5–10 ml/kg/hour. Only give vasopressor if trained- see Appendix D. Urgent empirical antimicrobials
Treat any additional source of infection. Antibiotics. Review results of investigations. Antimalarials (if RDT bedside malaria test positive). Antivirals – consider ribavirin in confirmed Lassa fever or CCHF. Identify any additional source of infection
Use signs or symptoms to consider source. Chest X-ray if portable machine available. AFB smear of sputums, if cough. Chest X-ray, Gram-stain sputum. Every 30 minutes until stable; then every 1 hour
Every 30 minutes until stable;
then every 1 hour
Respiratory rate. Respiratory rate. Mental status (AVPU) Mental status (AVPU). JVP, auscultate for crepitations. Check results of emergency laboratory JVP, auscultate for crackles (rales). If haemoglobin <7 mg/dl (Hct <20), consider transfusion with fresh whole Urine output. blood [reference anaemia section]. If glucose <3 mmol/l (54 mg/dl), then give 50% dextrose 25–50 ml (see Quick Check page 19). If respiratory function declining
If respiratory function declining (increasing
(increasing RR, falling SpO2)
RR, falling SpO2)
Check oxygen supply and fix. Check oxygen supply and increase flow rate if If wheezing, give salbutamol. If JVP elevated, increasing crepitations- consider fluid overload If elevated JVP and increasing crackles, consider fluid overload If suspect fluid overload, slow rate of fluid administration and start If wheezing, give salbutamol. vasopressors if stil in shock. If visible secretions and suction is available suction- realizing this may Check that antimicrobials have been given. produce an aerosol requiring additional respiratory protection (N95 or Treat other diagnoses or infections; see above. equivalent mask) If signs of fluid overload, SBP >100, and shock resolved, stop IV fluids, give furosemide 20 mg IV, and raise head of bed. 32 MANAGEMENT OF SEVERE CONFIRMED OR SUSPECTED CASES OF EBOLA/MARBURG OR CCHF
Manage Septic Shock: 6-24 Post-resuscitation
If no change in SBP fol owing fluid boluses - Perform ful reassessment. Reconsider the possible diagnoses. Review available diagnostic data and treat underlying diagnosis. Establish source of any additional infection. Could there be a surgical cause that would benefit from drainage? Evidence of a primary cardiac or pulmonary process? Add its specific Get a second opinion. Oxygen: Titrate to SpO2 90.
Oxygen: Titrate to SpO2 >90 and discontinue when 90 on room air.
Fluids: Reduce to maintenance maximum
When SBP >90, continue fluids at 2 ml/kg/hour. 2 ml/kg/hour and switch to oral when patient is able to take. If on vasopressors, reduce rate. If SBP <90, continue or increase vasopressors and continue LR or NS at 2 ml/kg/hour. Continue empirical antimicrobials – next dose
Continue antimicrobials – switch to oral dose
Antimalarials (if malaria test positive). Antimalarials (give IV antimalarials for at least 24 hours total before Ribavirin, if confirmed Lassa fever or CCHF. switching to oral). Ribavirin, if confirmed Lassa fever or CCHF. Add dextrose 50% 25-50 ml every 6 hour to the IV Procedures to fol ow once the patient has stabilized, or after 1–2 days: Due to risk of aspiration, do not give food oral y if patient cannot safely swal ow, (due to, e.g. altered mental status, severe shortness of breath, or severely il with ongoing vomiting). All other patients should be provided with food. Most patients lose their appetite when il and may find soft foods and fluids easier to tolerate. Smal frequent meals often are tolerated bet er. Consider NG feeding using semisolid (porridge or mashed foods) foods if the patient cannot swal ow safely and is not severely il . Give a smal amount initial y (e.g. 20–40 ml/hour) and monitor NG aspirates to check for absorption. Increase rate of feeding as tolerated. Every hour if SBP <90 or on vasopressors;
Every 8 hours (check SBP hourly if
otherwise every 2 hours
weaning off vasopressors); then daily
Respiratory rate. Respiratory rate Mental status (AVPU). Mental status (AVPU) JVP, auscultate for crackles (rales). Every 6 hours:
Respond to changes as indicated earlier. Urine output. Every 12 hours:
Repeat glucose and Hb if initial value abnormal.
Respond to changes as indicated for 2–6 hours on Respond to changes as indicated earlier. CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 33
ceftriaxone (2 gram daily IV) or ampicil in 2 grams every 6 hours plus gentamicin 1.5 mg/kg IV every 8 hours, plus ciprofloxacin. • Antimalarials: Do bedside RDT for malaria and if positive start artesunate IV, or if not available, IV quinine (see Appendix C for antimalarial doses) • Antivirals: Consider ribavirin in confirmed cases of Lassa fever and CCHF only. In addition to repeated measurement of SBP, pulse, respiratory rate and pulse oximetry, regular clinical examination is important for patients in shock. Pay particular at ention to the signs of poor perfusion and signs of fluid overload to help guide on-going management. Use the severely il patient monitoring form (Appendix D). • Signs of poor perfusion:
• decreased urine output
• altered mental status
Signs of fluid overload: worsening crepitations on auscultation dyspnoea elevated JVP peripheral oedema 34 MANAGEMENT OF SEVERE CONFIRMED OR SUSPECTED CASES OF EBOLA/MARBURG OR CCHF
4.3 Manage septic shock in children
Children can also be infectious. Use standard precautions (see section 7). Signs of shock Cold hands plus
Weak or absent pulse and either
Capil ary refil time > 3 seconds OR
AVPU less than Alert
Children in shock who require bolus fluid resuscitation are lethargic and have cold skin, prolonged capil ary refil , fast weak pulse and hypotension. 1. Check whether the child's hand is cold. If so, determine whether the child is in 2. Check whether the capil ary refil time is longer than 3 seconds. Apply pressure to whiten the nail of the thumb or the big toe for 5 seconds. Determine the time from the moment of release until total recovery of the pink colour. 3. If capil ary refil is longer than 3 seconds, check the pulse. Is it weak and fast? If the radial pulse is strong and not obviously fast, the child is not in shock. If you cannot feel the radial pulse of an infant (< 1 year old), feel the brachial pulse or, if the infant is lying down, the femoral pulse. If you cannot feel the radial pulse of a child, feel the carotid. (See the Emergency Triage Assessment and Triage guideline Normal pulse rate and blood pressure in childre
Pulse rate (range)
*Note: Normal pulse rates are 10% slower in sleeping children. In infants and children, the presence or absence of a strong central pulse is often a more useful guide to the presence or absence of shock than a blood pressure reading. CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 35
General principles of managing children with septic shock
• Manage airway (see ETAT). • Give oxygen through nasal prongs or catheter- start at 1-2 litres/min to aim for oxygen saturation ≥90%. • Give IV fluid – initial 20 ml/kg LR or NS bolus. See charts below. • Treat underlying cause: - Administer empirical broad spectrum antibiotics (eg ceftriaxone 80 mg/kg once daily - Antimalarials: Bedside RDT for malaria and if positive, start IV artesunate (or quinine if artesunate is not available) (see Appendix C for dosing) - Antivirals: Consider ribavirin in confirmed Lassa fever or CCHF • Consider vasopressors if failure of fluids and blood to raise SBP and if signs of inadequate perfusion persist. Note: the health worker must have been trained to use
vasopressors (SEE APPENDIX D)
• Monitor – record – respond. Initial intravenous fluid resuscitation for children with shock (and no
• Check that the child is not severely malnourished, as the fluid volume and rate are different (see below). • Insert an IV line (and draw blood for emergency laboratory investigations). • Attach Ringer's lactate or normal saline; make sure the infusion is running wel . • Infuse 20 ml/kg over 1 hour. 36 MANAGEMENT OF SEVERE CONFIRMED OR SUSPECTED CASES OF EBOLA/MARBURG OR CCHF
Urgent Fluid management – Child WITHOUT severe malnutrition27*
Plan C – Step 1
Plan C – Step 2
Plan B - 75 ml/kg
70 ml/kg Ringer's or ngt ORS
Oral /ngt ORS
Age <12m, over
Age <12 m, 1 hour
over 2 ½ hrs
Age ≥1 yr, ½ hour
Over 4 hours
** Assumes ‘adult' Reassess the child after the appropriate volume has been infused.
Reassess after first infusion
• Can repeat second bolus in second hour. If no response, give blood. •If whole blood, give 20 ml/kg over 2 to 4 hours. Reassess after second infusion If still low BP, consider vasopressors. CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 37
Emergency Fluid management in Severe Malnutrition28
Cold hands plus absent, slow (<60 bpm) or weak pulse and either capil ary refil >3 seconds or reduced consciousness. Give 15 ml/kg in 1 hour of Half Strength Dar ow's (HSD) in 5% dextrose or Ringers lactate. If HSD in 5% Dextrose not available it can be made by adding 50 ml 50% dextrose to 450 ml HSD (withdraw 50 ml from 500 ml bag first then add 50 ml of 50% dextrose). Urgent Fluid management – Child WITH severe malnutrition
Oral / ngt Resomal
Half-Strength Darrows in 5% Dextrose
HSD in 5% Dextrose
Oral / ngt
Drops/min if 20 drops/ml
10 ml/kg/hr for up
Hourly until transfusion
Shock= over 1 hour
to 10 hours
If child improves:
Repeat this bolus over another 1 hour.
Then switch to oral or ng fluids using ReSoMal at 10 ml/kg/hour for up to 10 hours.
As soon as conscious introduce F-75 and appropriately reduce amount of ReSoMal
If child does not improve:
Give maintenance IV fluids at 4 ml/kg/hr.
Transfuse 10 ml /kg whole blood over 3 hours as soon as it is available.
38 MANAGEMENT OF SEVERE CONFIRMED OR SUSPECTED CASES OF EBOLA/MARBURG OR CCHF
Introduce F-75 after transfusion complete. Follow fluid guidelines strictly to avoid fluid overload.
Watch carefully for signs
of fluid overload in children
Fluid overload is an important complication of treatment for shock. It can develop • Excess or too rapid IV fluids • Incor ect use of hypotonic rather than isotonic crystal oid solutions • Continuation of IV fluids for too long (once plasma leakage has resolved) • Use of large volumes of IV fluid in children with severe capil ary leakage Early signs:
• fast breathing • Chest indrawing • peri-orbital or soft tissue • Large pleural effusions Late signs:
• pulmonary oedema • cyanosis • irreversible shock (often a combination of ongoing hypovolaemia and cardiac failure)
The management of fluid overload varies depending on whether the
child is in or out of shock
Children who remain in shock and show signs of severe fluid overload are extremely dif icult to manage and have a high mortality. Avoid diuretics, as they wil cause further intravascular fluid depletion Aspiration of large pleural ef usions or ascites can be considered to relieve respiratory symptoms, but the risk of bleeding should be recognized. If shock has resolved but the child has fast breathing and large ef usions, consult with pediatric expert to consider giving oral or IV furosemide 1mg/kg once or twice a day for 24 hours (and oxygen therapy) If shock has resolved and the child is stable, stop IV fluids and keep the child on bed rest for 24-48 hours. The excess fluid wil be re- absorbed and lost through urinary diuresis. CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 39
40 MANAGEMENT OF SEVERE CONFIRMED OR SUSPECTED CASES OF EBOLA/MARBURG OR CCHF
5. Management of exposed individuals (contacts)
Individuals including health workers with percutaneous or mucocutaneous exposure to blood, body fluids, secretions, or excretions from a patient with suspected VHF should immediately wash the af ected skin surfaces with soap and water. Mucous membranes (e.g. conjunctiva) should be irrigated with copious amounts of water or eyewash solution. Exposed persons should be medical y evaluated and receive fol ow-up care, including fever monitoring, twice daily for 21 days after exposure. In case of temperature above 38.3°C (101°F), hospitalize immediately in strict isolation. The incubation period between exposure and clinical symptoms is a minimum of 48 hours. Health workers suspected of being infected should be isolated and the same recommendations outlined in this document must be applied until a negative diagnosis is confirmed. Contact tracing and fol ow-up of family, friends, co-workers, and other patients who may have been exposed to a VHF virus through close contact with the infected health workers is essential.
Possible use of ribavirin to high-risk contacts of CCHF patients
Post-exposure prophylaxis should be considered for those exposed to Lassa fever or CCHF. This should be limited to high-risk close contacts of the patients and laboratory and health care workers, defined as one of the fol owing: (1) Penetration of skin by a contaminated sharp instrument (e.g. needle stick injury); (2) Exposure of mucous membranes or broken skin to blood or bodily secretions (e.g. blood splashing in the eyes or mouth); (3) Participation in emergency procedures without appropriate personal protective equipment (e.g. resuscitation after cardiac ar est, intubation or suctioning) or (4) Prolonged (i.e. hours) and continuous contact in an enclosed space without appropriate personal protective equipment (e.g. a health worker accompanying a patient during medical evacuation in a smal airplane)29. In estimating infection risk, note that the most infectious patients are those with severe clinical conditions, usual y late in the course of il ness. Prophylaxis should not be used when the only exposure was during the incubation period or during convalescence after fever has CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 41
subsidedError! Bookmark not defined..
The prophylaxis dose is oral ribavirin 35 mg/kg loading dose (maximum 2.5 g) fol owed by 15 mg/kg (maximum 1 g) every 8 hours for 10 daysError! Bookmark not defined..
If a temperature of 38.3° C or higher develops, treatment with ribavirin can be considered as presumptive treatment of Lassa fever or CCHF. 42 MANAGEMENT OF EXPOSED INDIVIDUALS (CONTACTS)
6. Psychological support
Psychological support for the patient and the family are very important in the management of VHF. Anxiety and fear are normal given the high mortality rate for confirmed VHF. It is important to communicate wel with the patient and family, explaining the need for isolation and PPE, and to provide psychological support from the beginning of care. Make sure to do a complete mental health assessment in each patient; then look out for mental health problems developing as a result of patient's adjustment to being il . Depression, associated with feelings of hopelessness and/or suicidal thoughts, may be present. See Section 10.11 (Mental health problems) in the IMAI District Clinician Manual for their manageme Ideal y a psychologist or nurse skil ed in providing psychological support should be involved from the outset, but providing psychological care in PPE can be uncomfortable and dif icult. The PPE is physical y exhausting for the psychologist and for the patient it is dif icult to see the face of the psychologist (seeing faces helps to establish a good rapport). For mobile patients, an area can be created where the patients can talk over the fence of the high-risk area with the psychologist at suf icient distance to prevent infectioPsychosocial interventions for patients and families are described in Section 10.11 in the IMAI District Clinician ManuSupport groups for family members and for af ected patients after discharge may be useful. Control of pain, abdominal discomfort and nausea, and management of anxiety are important to the patient's wel -being (SEE SECTION 4). Patients who are terminal need
skil ed and thoughtful end-of-life care within the isolation facility.
For psychosocial and spiritual support for the patient and support for the bereavement, loss and grief experienced by family members, see also the IMAI-IMCI Palliative care:
symptom management and end-of-life guideline module30.
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 43
44 PSYCHOLOGICAL SUPPORT
7. Infection Prevention and Controla
Infection prevention and control is key to the reduction of spread of infection from patients to health workers, health workers to health workers, and from the patient to the rest of the community. Evidence from outbreaks strongly indicates that the main routes of transmission of VHF infection are 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. Avoiding transmission dictates strict adherence to standard precautions as wel as droplet and contact precautions for health care, environmental, and laboratory workers. Moreover, while epidemiology during VHF outbreaks does not suggest airborne transmission, precautions should be taken to avoid procedures or protect health workers, family members and other patients during procedures that might aerosolize virus.31 Al health workers (clinical and non-clinical) should use standard
precautions in caring for all patients, in all health facilities. These include:
• Hand hygiene • Appropriate personal protective equipment (PPE) based on risk assessment at the point of care • Respiratory hygiene • Prevention of injuries from needles and other sharp instruments • Safe waste disposal • Cleaning and disinfection of the environment • Safe handling of contaminated linens • Cleaning and disinfection of patient-care equipment The systematic application of these precautions should prevent the transmission of viral haemor hagic fever. a infection prevention and control recommendations in this document draw heavily on published WHO
INFECTION PREVENTION AND CONTROL 45 7.1 Recommendations for direct patient care for known
or suspected VHF patients
In addition to standard precautions, the following are WHO
recommendations for direct patient care for known or suspected viral
haemorrhagic fever patien
• Restrict al non-essential staf from patient care areas. • Maintain a register of al people entering the patient care area. • Limit the number of visitors al owed access to the patient to include only those necessary for the patient's wel -being and care, such as a spouse, child's parent or care-giver. • Ensure that al visitors use PPE according to the facility guidelines. Prior to entering the isolation area, provide al visitors with instructions on using PPE cor ectly, and instructions for cor ect hand hygiene practices- see il ustrations on page 44. Make sure they understand and practice the instructions strictly. • Do not al ow other visitors to enter the care area, and ensure that any visitors wishing to observe the patient do so from an adequate distance from the care area (approximately 15 meters). • Apply infection control precautions to avoid any possible unprotected direct contact with blood and body fluids when providing care to any VHF patient, including suspected cases. - Perform hand hygiene before and after direct patient care, after any contact with potential y contaminated surfaces, and after removal of PPE. Neglecting to perform hand hygiene after removing PPE wil reduce or negate any benefits of the protective equipment. - Wear cor ectly sized gloves (non-sterile examination gloves or surgical gloves) when entering the patient care area. - Wear a disposable, impermeable gown to cover clothing and exposed skin. Wear a waterproof apron over any permeable gown or when undertaking any strenuous activity (e.g. car ying a patient). - Wear facial protection to prevent splashes to the nose, mouth, and eyes. Facial protection can be achieved by means of (1) medical mask and eye protection (eye visor or goggles), or (2) with a face shield and medical mask. 46 INFECTION PREVENTION AND CONTROL
• Before exiting the isolation area of a patient with suspected VHF, careful y remove and dispose of protective equipment. • When removing protective equipment, be careful to avoid any contact between the soiled items (e.g. gloves, gowns) and any area of the face (eyes, nose, or mouth). • Ensure that clinical and non-clinical personnel are assigned exclusively to VHF patient care areas and that members of staff do not move freely between the isolation areas and other clinical areas during the outbreak. • Limit the use of needles and other sharp objects as much as possible. • Limit the use of phlebotomy and laboratory testing to the minimum necessary for essential diagnostic evaluation and patient care.
Specify who should wear protective clothing
• All doctors, nurses, and health workers who provide direct patient care to suspected • All support staff who clean the isolation room, handle contaminated supplies and equipment, launder re-usable supplies, and col ect and dispose of infectious waste from VHF patients. • All laboratory staff who handle patient specimens and body fluids from suspected VHF • Laboratory support staff who clean and disinfect laboratory equipment used to test VHF • Burial teams who remove bodies of deceased VHF patients and prepare them for • Family members who care for VHF patients. CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 47
7.2 Standard precautions- at al times, for al patients
Standard Precautions–At Al Times, For Al Patients
Ensure availability of hand-washing facilities with clean running water. Ensure availability of hand hygiene products (clean water, soap, single-use clean towels, and alcohol-based hand rub). Alcohol-based Handwashing
hand rubs should be made available at every point of care and are the standard of care. When to wash hands with soap and running water: • when hands are visibly dirty. When to use alcohol-based hand rub: • when hands appear clean (i.e. are not visibly soiled). • Do not wear artificial fingernails or extenders when having direct contact with patients.
• Keep natural nails short (tips less than 0.5 cm long or approximately ¼ inch).
• Keep a healthy skin.
• Avoid using rings, a wrist watch or bracelets.
• Ensure that hands are dry before starting any activity.
• Dry hands with single-use towels.
Indications for hand hygiene
Before and after any direct contact between a health worker and a patient and contact between patients, whether or not gloves are worn. Hands should be washed in the fol owing scenarios: • Before gloves are put on. • Immediately after gloves are removed. • Before handling an invasive device. • After touching blood, body fluids, secretions, excretions, non-intact skin, and contaminated items, even if gloves are worn. 48 INFECTION PREVENTION AND CONTROL
Standard Precautions–At Al Times, For Al Patients
• During care, e.g. when moving from a contaminated to a clean body site of the same • After contact with inanimate objects in the immediate vicinity of the patient. Respiratory hygiene
Educate al staff, health workers, patients, and hospital visitors: • Cover mouth and nose when coughing or sneezing. • Hand hygiene after contact with respiratory secretions. - Have single-use tissues available in the waiting area or provide a medical mask. Dispose of tissues in no-touch receptacles. Then wash hands. When tissues, cloths, or face masks are not available, instruct al staff, health workers, patients, and visitors to lift their arm up and cover their nose and mouth with the inner surface of the arm or forearm when they cough or sneeze. Cough or sneeze into
- For persons with respiratory symptoms: (1) source control measures- cover their nose and mouth with a tissue or mask when coughing or sneezing; (2) Spatial separation of at least one metre from persons with acute febrile respiratory symptoms. Use a tissue and then
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 49
Standard Precautions–At Al Times, For Al Patients
Prevention of injuries from needles and other
• Use care when handling, using, cleaning, and disposing of
needles, scalpels, and other sharps. • Do not bend, break, or otherwise manipulate used needles, scalpels, or other sharp instruments. • Do not recap needles. • Keep a sharps container nearby when giving injections. Discard single-use needles and syringes immediately after use and directly into the sharps container, without recapping and without passing to • Close, seal, and send sharps containers for incineration before they are completely ful .
Safe waste disposal
• Ensure safe waste management. • Treat waste contaminated with blood, body fluids, secretions, and excretions, and human tissue and laboratory waste directly associated with specimen, as clinical waste. Waste Management
• Segregate at the point of generation the 4 categories of - non-sharps infectious waste - non-sharp non-infectious waste - hazardous waste • Discard single use items properly. 50 INFECTION PREVENTION AND CONTROL
Standard Precautions–At Al Times, For Al Patients
Cleaning and disinfection of the environment
Use adequate procedures for the routine cleaning and disinfection of environmental and other frequently touched surfaces. • Floors and horizontal work surfaces should be cleaned at least once a day. • Cleaning should always be car ied out from "clean" areas to "dirty" areas, in order to avoid contaminant transfer. • Dry sweeping with a broom should never be done. Cleaning
Rags with dust should not be shaken out and surfaces should not be cleaned with dry rags. Cleaning with a moistened cloth helps to avoid contaminating the air with air-borne particles. • Clean BEFORE you disinfect.
• Change cleaning solutions and equipment frequently, as these items wil get
contaminated quickly (fol ow your hospital protocols).
Appropriate handling of contaminated linens
Handle, transport, and process used linen so as to: • Prevent skin and mucous membrane exposure and contamination of clothing. • Avoid transfer of pathogens to other patients or the environment: • Place al used linen and waste in bags or containers that are able to withstand transportation without being damaged. • Remove any solid matter on soiled linen and flush down a toilet. Cleaning and disinfection of patient care equipment
Handle equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposure, contamination of clothing, or transfer of pathogens to other patients or the environment. Clean, disinfect, sterilize, and reprocess reusable equipment appropriately before use with another patient. CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 51
7.3 Steps to put on and remove PPE
Viral haemor hagic fevers can be transmit ed person-to-person, usualy through direct contact with contaminated blood or body fluids of an infected person, or exposure to objects that have been contaminated with infected secretions. Infection probably occurs most often through oral or mucous membrane exposure (e.g., eyes, mouth, nose) or breaks in the skin. Presently, there is no evidence for human-to-human transmission of VHF through an airborne route. The folowing information about proper PPE during a VHF outbreak targets the front line-clinical provider and represents the minimum guidance to achieve appropriate protection for infection prevention and control. Importantly, during an outbreak, the types of PPE available in the field may not be the same across sites and may even dif er based on the organization providing them. Thus, it is imperative that the clinical team involved in triage and clinical management of patients assesses the evolving situation during the outbreak to determine whether the minimum requirements can be utilized or additional protective measures are necessary. In any case, it is important for clinicians to weigh the benefits of protecting themselves and patients against the risks of diminishing ef ective patient care through unnecessary bar iers or excessively uncomfortable protective equipment. Accordingly, the folowing instructions are an ilustration of the steps to put on and remove essential required PPE with some additional measures depending on the conditions occur ing during the outbreak: 52 INFECTION PREVENTION AND CONTROL
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 53
54 INFECTION PREVENTION AND CONTROL
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 55
56 INFECTION PREVENTION AND CONTROL
Apron and boots
Plastic or rubber aprons provide extra protection of the front part of the body. Ideal y disposable aprons should be used, but if non-disposable, aprons need to be disinfected by the person wearing it. This should include cleaning to remove gross contamination, disinfection and then hanging to dry outside the changing room in the sun. Boots should also be cleaned to remove gross contamination and then disinfected prior to re-use. Goggles or face shields
Goggles must fit comfortably and securely, and person should have his/her own goggles/face shield with their name on them. Goggles or face shields need to be disinfected by the person wearing them, washed with water and then hung outside the changing room to dry. Condensation of the goggles can be a major problem: it impairs the user's vision and is dangerous, but can be minimized by anti-fog spray. Protective gloves
The ef icacy of gloves in preventing contamination of health workers' hands and helping to reduce transmission of pathogens in health care has been confirmed in several clinical studies. Nevertheless, health workers should be informed that gloves do not provide complete protection against hand contamination. Pathogens may gain access to the caregivers' hands via smal defects in gloves or by contamination of the hands during glove removal. Hand hygiene by rubbing or washing remains the basis to guarantee hand decontamination after glove removal. Medical gloves are also single-use items. Glove decontamination and reprocessing are not recommended and should be avoided, even if it is common practice in many health-care set ings with low resources and where glove supply is limited. Disinfection by ‘spraying'
Hand-held spraying devices incorporating a chlorine solution have regularly been utilized in VHF outbreaks. This is general y as part of the ‘disinfection' process of PPE suspected of being the most heavily contaminated and CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 57
to al ow its subsequent re-use i.e. gloves, aprons and boots. Although the VHF viruses are susceptible to disinfection with chlorine solutions, generic principles of disinfection in healthcare facilities should be considered and raise doubt to the ef ectiveness of ‘spraying'. The first is that the presence of visible organic mat er such as blood or fecal material can interfere with the antimicrobial activity of disinfectants in at least two wa33. Most commonly, interference occurs by a chemical reaction between the disinfectant and the organic mat er resulting in a complex with less of the active germicide available for at acking the virus. Chlorine and iodine disinfectants, in particular, are prone to such interaction. Organic material also protects the virus from at ack by acting as a physical barrier and physical removal is required. Additional y items must be exposed to the disinfectant for the appropriate minimum contact time. Multiple scientific studies have demonstrated the ef icacy of a range of hospital disinfectants against pathogens with a contact time of at least 1 minute34. This supports the principle of utilizing disposable equipment in VHF set ings when possible, and when PPE is to be re-used it requires physical cleaning fol owed by disinfection with an adequate contact time. 58 INFECTION PREVENTION AND CONTROL
7.4 Flow through the isolation
ward, for patients and health
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 59
Discharge of an alert case is done on the fol owing conditions35 Patients have been reviewed by the VHF clinical management team and found to not meet the case definition of a suspected case, with no epidemiological link to any suspected or confirmed case. Have a conclusive diagnosis that is not VHF, recognizing that co-infections Have responded to specific treatment Be in good health condition and able to go back home Discharge of a VHF-confirmed case or suspected cases is based on the clinical presentation and the correct interpretation of the laboratory findings. Consider discharge when the fol owing criteria are met: Three or more days without fever or any significant symptom† Symptoms that suggest ongoing shedding of virus (e.g. diar hea, coughing, bleeding) should have completely disappeared. Viral shedding known to occur in the semen of male patients, and probably in the breast milk of lactating females, need not preclude discharge, but must be taken into consideration when providing instructions to the patient (see below) Significant improvement in clinical condition† In a relatively good general condition†: independently feeding and to carry out other activities of daily life, like washing and walking, without assistance, taking into account any previous disabilities. AND, if laboratory testing is available,
A negative blood PCR for VHF (regardless of any other serologic tests) on day 3 or later fol owing onset of symptoms. For patients with previous positive blood PCR tests, this means a subsequent negative test 48 hours from the initial test (regardless of serology). For previously blood PCR positive mothers, that are breast feeding, it may be safer to delay discharge until PCR on breast milk turns negative as wel CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 61
(to be discussed with the clinicians and laboratory present). †If a patient continues to suf er symptoms and/or their condition is not improving, but this is not thought to be due to acute filovirus disease, 2 negative blood PCR tests 48 hours apart, with at least one test being done 3 days or more after onset of symptoms, are needed before discharge/ referral to a normal ward for further care. Discharge package
• Mattress (4 inch) • Disinfectant -Jik/bleach • Assorted cloth • Clothing, if the patient's clothes were • Mosquito net (LLITN) destroyed on admission • A pair of Shoes • Kitchen wares (saucepan, plastic cup, plastic plate, jer ican, water bucket) • Sanitary pad (for female patients) • Laundry soap 62 DISCHARGE
9. Fol ow up
Discharged convalescent patients: They may remain weak and suf er persistent
symptoms. A system for fol ow-up care should be set up for these patients. If those
patients are discharged back home they often face stigmatization and/or rejection, so
discharge should be accompanied by the necessary psychosocial support and community
Patients that were admit ed but turned out not to be cases: If suf ering from another
disease, referral to a normal ward is sometimes needed. The normal health care system is
often unwil ing to accept these patients, or where they are accepted, their care may suf er from
neglect. Referral should therefore be fol owed up closely. If returned home, their community
may require assurance from medical authorities before accepting the patient.
Supportive treatment for all discharged patients
Provide one-month supply of vitamin supplements.
Nutritional advice. Identify local y available high-energy foods that are easy to digest,
rich in complex carbohydrates and balanced in fat, protein and fiber. Provide condoms. Also, provide instructions on using the condoms, and the minimum length of time they should be used (3 months). Breastfeeding women should stop breastfeeding until PCR testing of breast milk is negative. Infant feeding counseling and support should be provided according to the infant's age. Anticipate that rejection of discharged patients by their communities may occur. Therefore, the patient, his/her family and relatives, and health care personnel (if the patient is transferred) must be counseled to be sure that they understand that the patient does not constitute any danger. A medical certificate should be given at discharge to certify that the patient does not constitute any danger to his family and his neighbors. Psychological support and fol ow up should be considered, including advocacy on patients' behalf and interceding with community leaders where necessary. 64 FOLLOW UP
Case definitions for Ebola and Marbug virus disease during an epidemic:
A suspect case is any person:
Having had contact with a clinical c Presenting with acute fever (>38°C) OR Having had contact with a clinical case (suspect, probable or
Presenting with 3 or more of the symptoms below: OR Presenting with acute fever AND
Presenting with 3 or more of the concerning symptoms below: - Abdominal pain - Generalized or articular pain - Difficulty in swallowing - Intense fatigue - Difficulty in breathing - Nausea or vomiting - Loss of appetite OR Any person with unexplained bleedin miscarriage
OR Any unexplained death.
Cases are confirmed by laboratory testing, e.g. a positive PCR test Ebola or Marburg virus.
The definition of a probable case varies;
2 often used definitions are:
A suspect case that is known to have had contact with a known case (suspect, probable, or confirmed). OR A patient that is, on clinical and/or epidemiological grounds, very
likely to have Ebola or Marburg. Case definition for Ebola or Marburg outside of an epidemic:
An alert case is a patient presenting with:
Unexplained fever or history of fever (onset less than 3 weeks) Unexplained bleeding signs: - Haemorrhagic or purpuric rash - Blood in stool
- Expistaxis (nose bleed) - Blood in stool
- Haematemesis (blood in vomit) - Other haemorrhagic
- Haemoptysis (blood in sputum) AND
No known predisposing factors for haemorrhagic
OR A patient presenting with:
Any fever OR 3 more of the fol owing:
- Abdominal pain - Nausea or vomiting - Generalized or - Loss of appetite - Difficulty in swallowing - Difficulty in breathing - Intense fatigue Possible filovirus exposure: - Unexplained death(s) in the family or close contacts - Unexplained (cluster of) serious il ness in family or close - Provision of care for the seriously il or handing bodies (caretakers, health workers, those participating in traditional funerals) - At risk contact with apes or bats, dead or alive - When animals in the area, chiefly apes, die unexpectedly - Handling and/or eating "bush" animals (apes or bats) - Entry into caves or proximity to fruit trees that host bats 66 APPENDIX A1
Insert current country case definition CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 67
Case definition- suspected case of Lassa Fever
Known exposure to a person suspected to have Lassa fever
Fever >38°C for less than three weeks PLUS
Absence of signs of local inflammation AND
Two major signs or one major and two minor signs
Swollen neck or face Conjunctiva or subconjunctival hemorrhage Spontaneous abortion Diffuse abdominal pain /tenderness Petechial or hemorrhagic rash Chest/retrosternal pain New onset of tinnitus or altered hearing Persistent hypotension Absence of clinical response after 48 Generalized myalgia or arthralgia hrs to antimalarial and/or broad spectrum antibiotic therapy Profuse weakness 68 APPENDIX A2
Insert current country case definition Lassa fever:
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 69
Fluid plans A, B, and C (fluid and food)
Plan A: Treatment of diarrhoea at home
• Counsel the patient on the 3 rules of home treatment.
• Drink extra fluid.
• Continue eating.
• Advise the patient when to return to the health facility.
1. Drink extra fluid
Drink extra fluid: as much as the patient wil take safe fluid that is clean or has been boiled or disinfected ORS or other fluid (except fluids with high sugar or alcohol) drink at least 200–300 ml after each loose stool continue drinking extra fluid until the diarrhoea stops. It is especially important to provide ORS for use at home if the patient cannot return to the clinic if the diarrhoea worsens. If ORS is provided: o teach the patient how to mix and drink ORS o give 2 packets to take home. If the patient is vomiting, they should continue to take small sips. Antiemetics are usual y not necessary. 2. Continue eating 3. Return to the health facility when: • diarrhoea becomes worse • the patient has persistent diarrhoea or a large volume. 70 APPENDIX B
Plan B: Treatment of patient with some dehydration using ORS
1. Determine amount of ORS to give during first 4 hours.
• The approximate amount of ORS required (in ml) can be calculated by
multiplying the patient's weight (in kg) times 75.
• Use the patient's age if you do not know the weight.
• If the patient wants more ORS than shown, give more.
• Give the recommended amount of ORS in the clinic over a 4-hour period.
• If the patient is weak or vomits:
- give frequent small sips from a cup.
After a vomit, wait 10 minutes then continue, but more slowly.
2. After 4 hours
• Reassess the patient and classify for dehydration.
• Select the appropriate plan to continue treatment.
• Begin feeding the patient in the clinic.
3. If the patient must leave before completing treatment
• Show the patient how to prepare ORS solution at home.
• Show the patient how much ORS is needed to finish a 4-hour treatment
• Give enough ORS packets to complete rehydration.
Give 2 packets as recommended in Plan A.
4. Explain the 3 rules of home treatment
1. Drink extra fluid.
2. Continue eating.
3. Return to the health facility if needed.
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 71
Plan C: Treat severe dehydration quickly
Follow the arrows. If the answer is "yes" go across. If "no", go down. START HERE Can you give intravenous (IV) • Start IV fluid immediately. If the patient can drink, give ORS by mouth while the drip is set up. fluid immediately? YES
Give 100 ml/kg Ringer's lactate solution (or, if not available, normal saline), divided as follows: *Repeat once if radial pulse is very weak or not detectable. • Reassess the patient every 1–2 hours. If hydration status is not improving, give the IV drip Is IV treatment available nearby more rapidly. Also give ORS (about 5 ml/kg/hour) as soon as the patient can drink, usually after (within 30 minutes) YES
3– 4 hours (infant) or 1–2 hours for children, adolescents, and adults. • Reassess an infant for 6 hours and older patient after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment. Are you trained to use Refer URGENTLY to hospital for IV treatment. a naso-gastric (NG) tube for • If the patient can drink, provide a relative or friend with ORS solution and show how to give rehydration? YES
frequent sips during the trip. • Start rehydration by tube (or mouth) with ORS solution. Give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). • Reassess the patient every 1– 2 hours: Can the patient drink? YES
° if there is repeated vomiting or increasing abdominal distension, give the
fluid more slowly; ° if hydration status is not improving after 3 hours, send the patient for IV therapy.
Refer URGENTLY to hospital • After 6 hours, reassess the patient. Classify dehydration. Then choose the for IV or NG treatment. appropriate plan (A, B or C) to continue treatment. 72 APPENDIX B
Morphine, paracetamol and antimalarial dosing
for children and adults
Paracetamol and morphine
In adolescents and adult
dose in adults
4–6 hours, but no may be required 4 grams in in elderly or the very il , or when pain might becontrolled with doses every 6 hours. Oral morphine:
Initially, morphine According to sulphate 2.5–10 There is NO
tablets (10 mg or 30%–50% if pain respiratory rate. if patient is very IV or IM or
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 73 Paracetamol and morphine
Dose according to body weight
Paracetamol 10–15 Calculate exact dose based on weight of the child. Oral: 0.2–0.4 mg/kg every 4–6 h; increase if necessary for severe pain IM: 0.1–0.2 mg/kg every 4–6 h IV: 0.05–0.1 mg/kg every 4–6 h, or 0.005–0.01 mg/kg per hour by IV infusion 74 APPENDIX C
For adolescents and adults1:
How to give emergency antimalarial treatment
if falciparum malaria is possible
Preferred treatment is artesunate IV. Use artesunate or artemether rather than
quinine, if available. Give artesunate IV in patients in shock, if possible (except
for pregnant women in first trimester – give quinine).
QUININE IM or IV
ARTESUNATE IV or IM
(Always give glucose with Quinine)
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 75 Oral antimalarials (if no signs severe malaria):
Table: First-line antimalarial treatment options for P. falciparum in all
adolescent and adult patients except first-trimester pregnant patients*
Artesunate + Artemether/
amodiaquine lumefantrine twice
daily for 3 days*
daily for 3 days
DHP 40 mg + PQP
tablet 50 mg; lumefantrine 120
table 153 mg Morning Evening
8–13 yrs or smal or wasted The second dose on the first day should be given any time between 8 and 12 hours after the first dose. Dosage on the second and third days is twice daily (morning and evening). Lumefantrine absorption is enhanced by co-administration with fat. It is essential that patients or caregivers are informed of the need to take this ACT immediately after a fatty meal or drink – particularly on the second and third days of treatment.
76 APPENDIX C
Dose according to body weight Artemether
Give the maintenance dose daily for a minimum of 24 h until the patient can take oral artemisinin-based combination therapy. Artemether/
Tablet: 20 mg
artemether–120 mg lumefantrine twice per day Artesunate
dissolved in 0.6 ml of saline and sodium bicarbonate) in 3.4 ml of saline and glucose The IV solution should be prepared just before use. Dilute by dissolving 60 mg artesunic acid (which is already dissolved in 0.6 ml of 5% sodium bicarbonate) in 3.4 ml of 5% glucose. Give a dose at 0, 12 and 24 h and then daily until child is able to take it orally. If the patient is able to swallow, give the recommended full dose of artemisinin-based combination therapy. Oral: 4 mg/kg
Tablet: 25 mg
artesunate–55 mg Not recommended for children < 5 months of age owing to limited information CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 77 78 APPENDIX D
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 79 80 APPENDIX D
CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 81 APPENDIX E:
How to give vasopressors (peripheral
epinephrine or dopamine infusion)
In adolescents and adults1:
Mechanism: Vasopressors work by vasoconstriction and increasing the contractility of the heart. Commonly available vasopressor medications include epinephrine (adrenaline) and dopamine. Side-effects: There are many serious side-effects, notably tissue necrosis if the IV infiltrates, ar hythmias, and ischaemia to organs (skin, gut, kidneys). To minimize these risks, use the minimum dose possible to maintain the blood pressure (target SBP 90) and discontinue as soon the patient improves. Patients who are on a vasopressor infusion wil commonly develop tachycardia. The extremities may become cool or cyanotic due to peripheral vasoconstriction. Delivery: Vasopressors must be given careful y by intravenous infusion and are preferably given via a central venous catheter. However, central venous catheters should be placed only by a doctor who is skil ed in the cor ect technique and at a hospital where this type of IV access is used frequently and personnel are familiar with its care. Central venous catheters are associated with significant risks, notably pneumothorax, arterial puncture, and blood infection. See other guidelines for instructions on using a central venous catheter. If central venous access is not possible, it is acceptable to deliver vasopressor medications through a peripheral line with appropriate precautions. • Use the largest vein possible to deliver a high flow rate. • Always dilute the medication and give by infusion at a strictly control ed rate. • Use a bur ette to limit the volume and control the drip rate. • Use a metal gate-clamp in the IV rather than the integral rol er device, which can • Do not use the blood pressure cuff on the same arm through which the medication is 82 APPENDIX E
• Inspect the infusion site regularly to detect any extravasation of the medication into the tissues. Stop the infusion if: • the drip has infiltrated the tissues (e.g. severe pain and swel ing at infusion site) • the patient develops an ar hythmia (ir egular pulse or dangerous tachycardia). How to administer and titrate vasopressors 1. Does the patient have adequate perfusion? First, check if vasopressors are indicated. If a patient remains in shock and has clinical signs of poor perfusion (low BP, low urine output, altered level of consciousness) after IV fluid resuscitation, consider the use of vasopressor medications to temporarily support the circulation. Some pregnant women, patients with chronic il ness, and others may normal y have a SBP <90 mmHg but be awake and alert, with normal mental status, normal capil ary refil , and normal urine output. These patients may not need vasopressors to support blood pressure since they have no clinical signs of poor perfusion. 2. Choose a vasopressor and prepare the drip for infusion In most settings the choice of vasopressor is determined by what is available. Become familiar with the dosing and administration of the local y available vasopressor to optimize patient safety and prevent medication er ors. For most conditions leading to shock, there is no clear benefit of one vasopressor over the other. In cases of severe malaria, dopamine is prefer ed. The infusion should be dosed based on the patient's weight. If the patient cannot be weighed, estimate if the patient is smal (50 kg), average (60 kg), large (70 kg). Use the table below to calculate the cor ect dose. Have a col eague double-check that you are administering the cor ect medication in the cor ect dose and to the cor ect site. 3. Monitor the patient and titrate Frequent monitoring is required, as changes in pulse and blood pressure can occur very quickly. This may mean reducing or increasing the infusion rate within minutes of starting it. Continuous monitoring is prefer ed, but CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 83 How to give vasopressor by peripheral infusion
Peripheral dopamine infusion (preferred for Peripheral epinephrine infusion shock in severe malaria) Commonly available concentrations 1 amp = 1 mg epinephrine (adrenaline) 1 amp = 200 mg dopamine in 5 ml* Target infusion concentration 10 micrograms per ml 1000 micrograms per ml Mixing procedure to create target infusion concentration 2 amps in 200 ml normal saline** OR 1 amp dopamine in 200 ml normal saline** 10 amps in 1000 ml normal saline** OR 5 amps dopamine in 1000 ml normal saline** 0.05 mcg/ kg/ minute 0.2 mcg/kg/ minute for very hypotensive Infusion rate (ml/hour)**** Patient weight (kg) * 1 milligram (mg) is equal to 1000 micrograms (mcg). ** Read ampoule label 3 times to confirm concentration before mixing. *** Desired dose rate is weight-based. **** Infusion rate is commonly presented per hour. Infusion rate = desired dose rate or concentration of the infusion. In children2:
200 mg/5 ml ampoule Calculate exact dose based on body For treatment of shock that is Dilute to 250 mg in 250 ml of 0.9% weight and required rate of infusion. sodium chloride with 5% glucose to 1000 µg/ml 84 APPENDIX E
INFECTION CONTROL – Non-patient care activities for known or
suspected VHF patients
Diagnostic laboratory activities
Activities such as micro-pipet ing and centrifugation can mechanical y generate fine aerosols that might pose a risk of transmission of infection through inhalation. Laboratory personnel handling potential VHF clinical specimens should wear gown, gloves, particulate respirators (e.g., EU FFP2, US NIOSH- certified N951) and eye protection or face shields, or powered air purifying respirators (PAPR) when aliquot ing, performing centrifugation or undertaking any other procedure that may generate aerosols. When removing protective equipment, avoid any contact between the soiled items (e.g. gloves, gowns) and any area of the face (i.e. eyes, nose or mouth). Perform hand hygiene immediately after the removal of protective equipment used during specimen handling and after any contact with potential y contaminated surfaces. Place specimens in clearly-label ed, non-glass, leak-proof containers and deliver directly to designated specimen handling areas. Disinfect al external surfaces of specimen containers thoroughly (using an ef ective disinfectant) prior to transport. (Example of ef ective disinfectant: sodium hypochlorite at 0.05%, 500 ppm available chlorine (i.e. 1:100 dilution of household bleach at initial concentration of 5%). Post-mortem examinations
Post-mortem examination of V HF-patient remains should be limited to essential evaluations only and should be performed by trained personnel. CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 85 Personnel examining remains should wear eye protection, mask, gloves and gowns as recommended for patient care. In addition, personnel performing autopsies of known or suspected VHF patients should wear a particulate respirator and eye protection or face shield, or a powered air purifying respirator (PAPR). When removing protective equipment, avoid any contact between soiled gloves or equipment and the face (i.e. eyes, nose or mouth). Hand hygiene should be performed immediately fol owing the removal of protective equipment used during post-mortem examination and that may have come into contact with potential y contaminated surfaces. Place specimens in clearly-label ed, non-glass, leak-proof containers and deliver directly to designated specimen handling areas. All external surfaces of specimen containers should be thoroughly disinfected (using an ef ective disinfectant) prior to transport. Tissue or body fluids for disposal should be careful y placed in clearly marked, sealed containers for incineration. Movement and burial of human remains
The handling of human remains should be kept to a minimum. The fol owing recommendations should be adhered to in principle, but may need some adaptation to take account of cultural and religious concerns: Remains should not be sprayed, washed or embalmed. Only trained personnel should handle remains during the outbreak. Personnel handling remains should wear personal protective equipment (gloves, gowns, apron, surgical masks and eye protection) and closed shoes. Protective equipment is not required for individuals driving or riding in a vehicle to col ect human remains. 86 APPENDIX F
Protective equipment should be put on at the site of col ection of human remains and worn during the process of col ection and placement in a body bag. Protective equipment should be removed immediately after remains have been placed in a body bag and then placed inside a cof in. Remains should be wrapped in sealed, leak-proof material and should be buried Cleaning
Environmental surfaces or objects contaminated with blood, other body fluids, secretions or excretions should be cleaned and disinfected using standard hospital detergents/disinfectants. Application of disinfectant should be preceded by cleaning. Do not spray (i.e. fog) occupied or unoccupied clinical areas with disinfectant. This is a potential y dangerous practice that has no proven disease control benefit. Wear gloves, gown and closed shoes (e.g. boots) when cleaning the environment and handling infectious waste. Cleaning heavily soiled surfaces (e.g. soiled with vomit or blood) increases the risk of splashes. On these occasions, facial protection should be worn in addition to gloves, gown and closed, fluid-resistant shoes. Soiled linen should be placed in clearly-label ed, leak-proof bags or buckets at the site of use and the container surfaces should be disinfected (using an ef ective disinfectant) before removal from the site. Linen should be transported directly to the laundry area and laundered promptly with water ad detergent. For low-temperature laundering, wash linen with detergent and water, rinse and then soak in 0.05% chlorine for approximately 30 minutes. Linen should then be dried according to routine standards and procedures. Linen that has been used by VHF patients can be heavily contaminated with body fluids (e.g. blood, vomit) and splashes may result during handling. When handling soiled linen from VHF patients, use gloves, gown, closed shoes and facial protection. If safe cleaning and disinfection of heavily soiled linen is not possible or reliable, it may be prudent to burn the linen to avoid any unnecessary risks to individuals CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 87
handling these items. Waste management during VHF outbreaks
Waste should be triaged to enable appropriate and safe handling. Sharp objects (e.g. needles, syringes, glass articles) and tubing that have been in contact with the bloodstream should be placed inside puncture resistant containers. These should be located as close as practical to the area in which the items are used. Col ect al solid, non-sharp, medical waste using leak-proof waste bags and Waste should be placed in a designated pit of appropriate depth (e.g. 2 m deep and fil ed to a depth of 1–1.5 m). After each waste load the waste should be covered with a layer of soil 10–15 cm deep. An incinerator may be used for short periods during an outbreak to destroy solid waste. However, it is essential to ensure that total incineration has taken place. Caution is also required when handling flammable material and when wearing gloves due to the risk of burn injuries if gloves are ignited. Placenta and anatomical samples should be buried in a separate pit. The area designated for the final treatment and disposal of waste should have control ed access to prevent entry by animals, untrained personnel or children. Wear gloves, gown and closed shoes (e.g. boots) when handling solid infectious waste. Waste, such as faeces, urine and vomit, and liquid waste from washing, can be disposed of in the sanitary sewer or pit latrine. No further treatment is necessary. Wear gloves, gown, closed shoes and facial protection, when handling liquid infectious waste (e.g. any secretion or excretion with visible blood even if it originated from a normal y sterile body cavity). Avoid splashing when disposing of liquid infectious waste. Goggles provide greater protection than visors from splashes that may come from below when pouring liquid waste from a bucket. 88 ABBREVIATIONS, ACRONYMS AND DEFINITIONS
List of abbreviations, acronyms and definition of some medical terms
A fine mist or spray that contains minute particles Acid-fast bacil us Antibody
Type of protein in the blood that produces immunity against microorganisms or their toxins A molecule or substance that is recognized by the immune system, which triggers an immune response, such as the release of antibodies Arthralgia
Alert, responding to voice, responding to pain, unresponsive
Beats per minute Blood urea nitrogen Case definition
Criteria for deciding whether a person has a particular disease A person or animal that harbors a specific infectious agent without visible symptoms of the disease. A car ier acts as a potential source of infection. Crimean-Congo Haemorrhagic Fever Center for Disease Control and Prevention Central Public Health Laboratory Dysphagia
Painful swal owing Enzyme-Linked-Immunosorbent Assay Therapeutic milk (see recipe in the Pocket book of hospital care for childre Vomiting of blood CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 89
Coughing up blood An organism in which a parasite lives and by which it is nourished. Immune globulin M Immune globulin G Integrated Management of Adolescent and Adult Illness Integrated Management of Childhood Illness Period that the patient is infected with the virus, but is stil Incubation Period
asymptomatic and not contagious yet Infection Prevention and Control Jugular venous pressure Multiple Organ Failure Ministry of Health Medecins Sans Frontieres Non-governmental organization Nasogastric tube Nosocomial Infection
An infection acquired at a hospital or other healthcare facility. Non-steroidal anti-inflammatory drug An accumulation of an excessive amount of watery fluid in cel s and tissues of the body 90 ABBREVIATIONS, ACRONYMS AND DEFINITIONS
Oral rehydration salt(s) Powered Air Purifying Respirators Photophobia
Painful oversensitivity to light Polymerase Chain Reaction Personal Protective Equipment Rehydration solution for malnutrition Rapid Diagnostic Test Any person, animal, anthropoid, plant, or substance which can harbor Reservoir
infection and hence act as a source of disease outbreak. Respiratory rate Systolic blood pressure Oxygen saturation Tachypnoea
United Nations Children's Fund Uganda Viral Research Institute Viral Haemorrhagic Fever World Health Organization CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 91
92 ABBREVIATIONS, ACRONYMS AND DEFINITIONS
Aggression in non-cooperative patient . 25 Anxiety . 25, 43 As history of exposure . 6 Management in VHF patients . 27-28 Case definitions for Ebola/Marburg Suspect case (during an epidemic) . 65 Probable case (during an epidemic). 65 Confirmed case. 65 Alert case (outside an epidemic) . 66 Special considerations in VHF . 28 Management septic shock . 35-39 Fluid management plans B and C- no malnutrition . 37 Fluid management- severe malnutrition . 38 Clinical features Ebola/Marburg . 9-10, 13-14 Clinical monitoring forms . 78 In cooperative patient . 25 CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 93
In non-cooperative patient . 25 Contacts (exposed individuals) . 41 Crimean-Congo haemor hagic fever (CCHF) History of exposure . 8 Key clinical features . 11-12 Laboratory diagnosis . 12, 17-18 Manage exposed individuals . 41-42 Dengue (note: these guidelines do not apply to dengue). 1 Diar hoea, dehydration . 24 Fluid plans A, B, C . 70 Difficulty breathing/respiratory distress. 24 During management septic shock . 31-34 Fol ow up after discharge . 63 Case definitions . 65 History of exposure . 5-6 Key clinical features . 9-10, 13-14 Laboratory diagnosis . 17 Manage exposed individuals . 41 Exposed individuals- see Contacts 94 REFERENCES
Differential diagnosis . 3,8,12 In adults . 31-34 In children . 39 Fluid plans A, B, C . 70 Hypoglycaemia . 25 Infection prevention and control Isolation ward flowchart . 58 Non-direct patient activities . 85 Personal protection equipment (PPE) . 52-56 Recommendations for direct patient care, in addition to standard precautions . 46-47 Standard precautions . 45, 48-51 Jugular venous pressure . 31 Laboratory diagnosis Ebola/Marburg, Lassa fever, CCHF . 17-21 Infection control precautions. 17-,20 Malaria testing . 18 Notification . 21 Other laboratory tests . 20 Point-of-care testing . 20 Case definitions . 68 History of exposure . 7 Key clinical features . 10-11 Laboratory diagnosis . 17 CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 95
Manage exposed individuals . 41-42 Fluid management in children with severe malnutrition . 38 In differential diagnosis VHF. 9 Testing for malaria (RDT) . 18 Antimalarial treatment doses . 73 Marburg- see Ebola/Marburg Pain management . 24 Morphine . 24, 73-74 Paracetamol . 24, 73-74 Symptom management- see pain, fever, anxiety Terminal care . 43 Personal protective equipment (PPE) . 52-56 Pregnancy- special considerations . 27 Psychological support . 43 Reporting suspected VHF. 15 Ribavirin for Lassa fever and CCHF Management in adults, adolescents . 31-34 Management in children . 35-39 Standard precautions 96 REFERENCES
Hand hygiene . 48 Respiratory hygiene . 49 Prevent injuries- needles, other sharp instruments . 50 Safe waste disposal . 50 Cleaning, disinfection . 51 Appropriate handling contaminated linens . 51 Clean, disinfect patient care equipment . 51 Suspected cases VHF Case definition . 65 Response to suspected case . 15-16 Indications in adults . 31-33 Indications in children . 36-37 How to administer . 82 Yel ow fever (note: these guidelines do not apply to yel ow fever) . 1 CLINICAL MANAGEMENT OF PATIENTS WITH VIRAL HAEMORRHAGIC FEVER 97
Ministry of Health reviewers [insert during country adaptation]:
Implementing partner contributors to the original Ugandan version; those also contributing to this generic version for West African adaptation are marked with asterick *: • Shevin T Jacob, MD MPH - Austere Environments Consortium for Enhanced Sepsis Outcomes (ACESO), IMAI-IMCI Alliance and University of Washington* • Sandy Gove, MD, MPH - IMAI-IMCI Al iance* • Armand Sprecher, MD MPH – MSF • Tom Fletcher MD- Liverpool School of Tropical Medicine • Nathan Kenya-Mugisha MD, IMAI-IMCI Alliance Uganda • Henry Kyobe Bosa, MBChB MSc - Uganda People's Defense Forces/ African Union Mission in Somalia Expert reviewers: • James Lawler - Naval Medical Research Center-Frederick, Virginia; ACESO • Sheik Humar Khan - Kenema General Hospital, Sier a Leone • Jean-Paul Gonzalez – Metabiota • Dan Bausch - US Naval Medical Research Unit – 6, Tulane University The original Ugandan version of this manual was developed under the direction of Dr Jacinto Amandua, MD, Commissioner Clinical Services, MOH Uganda Development of the original Ugandan version of this manual and its adaptation for its use in West and Ce ntral Africa was supported by funding from the government of USA (DOD DTRA) and the Government of Japan through grants to WHO/HSE/ Pandemic and Epidemic Diseases ( PED) (project manager Nikki Shindo) , with the support of WHO regional office for Africa (Francis Kasolo, Benido Impouma) and the WHO country offices in af ected countries. Produced by the IMAI-IMCI Al iance. Design and illustrations: Robert Thatcher. 98 REFERENCES
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Patients with Suspected or Confirmed Filovirus (Ebola, Marburg) Hemorrhagic Fever. Geneva March 2008. 2003, 327:1271-1275 (29 NOVEMBER 2003 bmj.com) 7 Appannanavar SB, Mishra B. An update on Crimean Congo hemorrhagic fever. Journal of Global Infectious Disease 2011, 3: 285–292. 8 http://www.cdc.gov/vhf/crimean-congo/transmission/index.html 9 Erbay A, et al. Breastfeeding in Crimean-Congo haemorrhagic fever. Scandanavian Journal of Infectious Disease.2008; 40: 186-8. 10 Kortepeter MG, Bausch, DG, Bray, M. Basic clinical and laboratory features of filoviral hemorrhagic fever. Journal of Infectious Diseases 2011, 204: S810-S816 11 Sterk E. Filovirus haemorrhagic fever guidelines. Médecins Sans Frontières. Barcelona 2008. 12 Dahmane A et al. Constraints in the diagnosis and treatment of Lassa Fever and the effect on mortality in hospitalized children and women with obstetric conditions in a rural district hospital in Sierra Leone. Transactions Royal Society Tropical Medicine and Hygiene 2014, 108: 126–132. 13 Blumberg L, Enria D, Bausch DG: Viral haemorrhagic fevers, in Manson's tropical diseases, in press- 2014. 14 McCormick, JB, Fisher-Hock, SP. Lassa fever. Current Topics in Microbiology and Immunolology 2002, 262:75-109. 15 McCarthy- Lassa reference [find correct reference] 16 Cummins D, et al. Acute sensorineural deafness in Lassa fever. The Journal of the American Medical Association 1990, 264:2093-2096. 17 Vorou R, et al. Crimean-Congo hemorrhagic fever. Curr Opin Infect Dis 2007; 20:495–500. 18 Hatipoglu CA, et al. Evaluation of clinical and laboratory predictors of 100 REFERENCES
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etiology. 27 Bray M and Mahanty S, Ebola Hemorrhagic Fever and Septic Shock, The Journal of Infectious Diseases 2003 188:11, 1613-1617 28 Uganda ETAT guidelines 29 Bausch, DG et al. Review of the literature and proposed guidelines for the use of oral ribavirin as postexposure prophylaxis for Lassa Fever, Ribavirin Postexposure Prophylaxis, CID 2010, 51:1435-1441. 30 IMAI-IMCI Palliative care: symptom management and end-of-life care. WHO, 2004. Available at: www.who.int/hiv/pub/imai/genericpalliativecare082004.pdf 31 Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence - Advisory Committee on Dangerous Pathogens 2012. Available at: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947382005. 32 Favero MS. Naturally occurring microrganisms and their resistance to physical and chemical agents. In: Rutala WA, ed. Disinfection, sterilization and antisepsis: Principles, practices, challenges, and new research. Washington DC: Association for Professionals in Infection Control and Epidemiology, 2004:1-14 33 Lewis DL, Arens M. Resistance of microorganisms to disinfection in dental and medical devices. Nature Medicine 1995; 1:956-8. 34 Rutala et al. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Centers for Disease Control and Prevention. Available at: <http://www.cdc.gov/hicpac/Disinfection_Sterilization/toc.html> 35 Amone, J. Case management of Ebola at health facility: experience from Kagadi hospital, by Dr Jackson Amone, National Coordinator ACHS (IC) – MOH. Derived from powerpoint presentation, Quick Check Stakeholders Meeting, Kampala, Uganda. 19 October 2012. 102 REFERENCES
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018530 - SWITCH Sustainable Water Management in the City of the Future Integrated Project Global Change and Ecosystems Training material Pharmaceutical compounds in environment Removal of pharmaceuticals from concentrated wastewater streams in source oriented sanitation Prepared by: dr. ir. Katarzyna Kujawa-Roeleveld Wageningen University, Wageningen, The Netherlands LeAF (Lettinga Associates Foundation) Based on deliverables of SWITCH project, other overlapping projects and literature Material to be used with PowerPoint presentations I-VIII