Clinical Viral haemorrhagic fevers (VHF): Standard Operating Procedures Document Control Summary Status: New Version: v1.0 Date: January 2016 Author/Title: Owner/Title: Judy Carr - Lead Infection Prevention and Control Nurse Kenny Laing - Deputy Director of Nursing Approved by: Policy and Procedures Committee Date: 19/01/2017 Ratified: Policy and Procedures Committee Date: 19/01/2017 Related Trust Strategy and/or Strategic Aims Provide high quality services, built on best known practice and evaluated through clear process and outcome measures Implementation Date: January 2017 Review Date: January 2020 Key Words: Associated Policy or Standard Operating Procedures Ebola Infection Prevention and Control Policy Contents 1. Introduction... 2 2. Purpose... 3 3. Scope... 3 4. Clinical features... 3 5. Transmission... 4 6. Management of patients whom you suspect have VHF... 4 7. Risk Categories for VHF... 5 8. Recommended General IPC measures... 5 9. PPE for possible VHF patients can be found at... 6 10. PPE risk assessment... 7
11. Management of a patient categorised as low possibility of VHF... 8 12. Management of a patient categorised as high possibility of VHF... 9 13. Management of a patient categorised as confirmed VHF... 10 14. Cleaning... 11 15. Crockery and cutlery... 12 16. Linen and laundry... 12 17. Toilets... 12 18. Waste... 12 19. Sharps Waste.... 12 20. Transport of Suspected Viral haemorrhagic fevers patients... 12 21. What to do for patients in the community... 12 22. Assessment, categorisation and management of contacts... 13 23. External Contact List... 14 24. Mortuary Arrangements... 14 25. References... 14 Appendices: (for Appendices please see separate associated documents) Trigger Card Viral Haemorrhagic Fever Risk Assessment Steps to remove PPE Management algorithm for suspected cases of Viral Haemorrhagic Fever Action sheet for nurse in charge of ward Action sheet for IPC team Action sheet for hospital co-ordinator Action sheet for on call Executive Action card for taking clinical specimens Isolation card for outside room Contact list for staff Change Control Amendment History Version Dates Amendments 1. Introduction VHFs are severe and life-threatening viral diseases that are endemic in parts of Africa, South America, the Middle East and Eastern Europe. Environmental conditions in the UK do not support the natural reservoirs or vectors of any of the haemorrhagic fever viruses. All recorded cases of VHF in the UK have been acquired abroad, with one exception of a laboratory worker who sustained a needle-stick injury. There have been no cases of person-to-person transmission of VHF in the UK to date of publication of this SOP. VHFs are of particular public health importance because: They can spread readily within a hospital setting; They have a high case-fatality rate; Page 2 of 14
They are difficult to recognise and detect rapidly; There is no effective treatment. 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. Experts agree that there is no circumstantial or epidemiological evidence of an airborne transmission risk from VHF patients. Causative organisms Of 15 VHF, 4 are more commonly known: Ebola (Filoviridae) Lassa (Arenaviridae) Crimean/Congo haemorrhagic fever caused by Nairovirus (Bunyaviridae) and Marburg 2. Purpose This document provides guidance on the risk assessment and management of patients in the Trust in whom infection with a Viral Haemorrhagic Disease (VHD) is SUSPECTED or CONFIRMED This guidance aims to eliminate or minimise the risk of transmission to health care workers and others coming into contact with an infected patient or their samples. 3. Scope This SOP applies to all staff working for the Trust including contracted service providers. This policy may be subject to change at short notice based on advice from the Department of Health. 4. Clinical features Viral haemorrhagic fevers are severe and life-threatening viral diseases Typical signs and symptoms include: sudden onset of fever, >37.5 degrees C intense weakness, muscle pain, headache sore throat. This is followed by vomiting, diarrhoea, rash, impaired kidney and liver function and in some cases, both internal and external bleeding. Laboratory findings include low white blood cell and platelet counts and elevated liver enzymes. Viral haemorrhagic fevers virus infections can only be confirmed through laboratory testing. Page 3 of 14
5. Transmission Environmental conditions in the UK do not support the natural reservoirs or carriers of any of the haemorrhagic disease viruses, and all recorded cases of VHD in the UK have been acquired abroad. The incubation period is 2 to 21 days. The patient becomes contagious once they begin to show symptoms. They are not contagious during the incubation period. Infection occurs from direct contact through broken skin or mucous membranes with the blood, or other bodily fluids or secretions (stool, urine, saliva, semen) of infected people. Infection can also occur if broken skin or mucous membranes of a healthy person come into contact with environments that have become contaminated with an Viral haemorrhagic fevers patient s infectious fluids such as soiled clothing, bed linen, or used needles. The Virus may be present In blood In body fluids, including urine On contaminated instruments and equipment In waste On contaminated clothing On contaminated surfaces Exposure to virus may occur: directly, through exposure (broken skin or mucous membranes) to blood and/or body fluids during invasive, aerosolising or splash procedures; indirectly, through exposure (broken skin or mucous membranes) to environments, surfaces, equipment or clothing contaminated with splashes or droplets of blood or body fluids. It is not always possible to identify patients with Viral haemorrhagic fevers early in the course of their illness because initial symptoms may be non-specific. For this reason, it is important that Health Care Workers at all levels carefully apply standard precautions on a consistent basis, with all patients regardless of their diagnosis in all practices and at all times. The risk of person to person transmission is highest during the latter stages of the illness when vomiting, diarrhoea and often haemorrhage may lead to splash and droplet generation. People are infectious as long as their blood and secretions carry the virus. Viral haemorrhagic fevers virus has been isolated from semen sixty one days after onset of illness. 6. Management of patients whom you suspect have VHF You should suspect a case of Viral haemorrhagic fever for any patient who: High fever > 37.5 degrees C Recent history of travel to a high risk country within last 21 days Contact with a known or SUSPECTED case within the last 21 days Page 4 of 14
Contact with samples from a SUSPECTED or known case within the last 21 days Severe symptoms of viral disease sudden onset of fever, intense weakness, muscle aches and pains, sore throat, bruising or bleeding These symptoms are usually followed by vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases internal and external bleeding. If you suspect a case of Viral haemorrhagic fevers 1. A senior member of the medical team should follow the major steps in the pathway from the identification to diagnosis in the patient risk assessment algorithm, (see associated documents) This will establish the patients Viral haemorrhagic fevers risk category, which determines the subsequent management of the patient and the level. This must be done without delay in order to ascertain the status of the patient to avoid placing others at risk. Then follow the management algorithm for suspected cases of viral haemorrhagic fever (see associated documents) and the Action cards (see associated documents) 7. Risk Categories for VHF There are three possible categories shown below in Figure 1. Figure 1 Low possibility of Viral haemorrhagic fevers High Possibility of Viral haemorrhagic fevers Confirmed Viral haemorrhagic fevers Inform The on call Consultant Microbiologist via Queens Hospital Burton switchboard on 01283 56633 who will then contact Public Health England Infection Prevention and Control Team Tel, 01785 221483 or Mobile 07971313156 Hospital Coordinator 8. Recommended General IPC measures Patients with suspected Viral haemorrhagic fevers should be isolated immediately in a single room with en suite facilities. Personal protective equipment (PPE) must be used but the level of protection required will depend on the patient s symptoms, see figure 2. Failure to wear appropriate PPE places the individual at considerable risk Infection Prevention and control instructions should be placed outside the room. See Appendix 8. Access to this area should be restricted and visitor access should be limited to those essential for the patients well being for example parent / child Dedicated equipment should be used. Page 5 of 14
One staff member should be named to oversee adherence to IPC measures and to coordinate activities and to provide advice. Clinical and non clinical personnel should be exclusively assigned to the patient. The number of staff in contact with the patient should be restricted. A contact list of all staff who have had contact with the patient should be maintained by the area where the patient is being cared for, see Appendix 9. Use of phlebotomy and laboratory testing should be limited to the minimum essential. Staff who obtain blood specimens from these patients should take particular care not to sustain a needle stick injury and must use the needle safe devices provided, without modification. Follow the Action cards Appendices 5,6,7 9. PPE for possible VHF patients can be found at: ST. GEORGE S HOSPITAL Chief Executive s office, Mellor House Reception, Mellor House Hospital Co-ordinator Hatherton Centre Reception THE REDWOODS CENTRE Crisis Resolution Office BURTON UPON TRENT Horninglow Clinic, (Clinical room) TELFORD 14 Leonard Street, Oakengates THE GEORGE BRYAN CENTRE Reception Page 6 of 14
10. PPE Risk Assessment Figure 2 PPE during patient management Patients categorised as a low risk Standard precautions Gloves Plastic aprons Additional protection for splash inducing procedures Fluid repellent surgical facemask Eye protection Additional protection for potential aerosol generating procedures FFP3 respirator or EN certified equivalent Eye protection Patients categorised as a high risk Standard precautions plus droplet pre Hand Hygiene Double Gloves Fluid repellent disposable coverall or gown Full length plastic apron Head cover e.g. surgical cap Fluid repellent footwear e.g. surgical boots shoes covers Full face shield or goggles Fluid repellent FFP3 respirator used as splash protection. Wearers should undergo face fit test Don t touch your face or adjust PPE with contaminated gloves Don t touch environmental surfaces except as necessary during patient care The correct method of removing PPE is important to ensure that there is no direct contact with blood or body fluids of a suspected case. (see associated documents) Page 7 of 14
11. Management of a patient categorised as low possibility of VHF Low possibility of Viral haemorrhagic fevers The patient should be nursed in a single side room with dedicated en-suite facilities until the possibility of transmissible infection has been ruled out. Samples can be treated as standard samples Infection prevention and control measures for low possibility of Viral haemorrhagic fevers Staff Protection Control Measures Standard precautions Hand Hygiene Gloves Plastic aprons Additional protection for splash inducing procedures Additional protection for potential aerosol generating procedures based on a risk assessment for other infections known to be transmitted by aerosol. Fluid repellent surgical facemask Eye protection FFP3 respirator or EN certified equivalent Eye protection Potential aerosol generating procedure include Endotracheal intubation Airway suctioning Page 8 of 14
12. Management of a patient categorised as high possibility of VHF High Possibility of Viral haemorrhagic fevers The patient should be nursed in a single side room with dedicated en-suite facilities to limit contact. The number of staff in contact with the patient should be restricted and staff should be used exclusively for Viral haemorrhagic fevers patient care. The level of staff protection required is dependent on the patient s symptoms and is set out in the next table. Infection prevention and control measures for high possibility of Viral haemorrhagic fevers Staff Protection Control Measures Standard precautions plus droplet Hand Hygiene precautions Double Gloves Fluid repellent disposable coverall or gown Full length plastic apron Head cover e.g. surgical cap Fluid repellent footwear e.g. surgical boots shoes covers Full face shield or goggles Fluid repellent FFP3 respirator used as splash protection. Wearers should undergo face fit test If the patient is bruised or bleeding or has uncontrolled diarrhoea or uncontrolled vomiting, the lead clinician should ensure that Viral haemorrhagic fevers testing is carried out and have an urgent discussion with High Level Isolation Unit (HLIU) concerning patient management and possible early transfer to HLIU Single use disposable equipment and supplies should be used. Page 9 of 14
13. Management of a patient categorised as confirmed VHF Confirmed Viral haemorrhagic fevers Patient with confirmed VHF A patient who has had a positive VHF screen result should be managed in an HLIU, unless exceptional circumstances prevent transfer of the patient; Full public health actions should be launched; Once the patient has been transferred, testing of specimens should be carried out in the dedicated laboratory at the HLIU. If a patient has a confirmed VHF, the following urgent actions are required: Restrict the number of staff in contact with the patient; staff should be used exclusively for Viral haemorrhagic fevers patient care Compile a list of all staff who have been in direct contact with the patient; Enhance levels of personal protection for those in direct contact with the patient: Hand hygiene; Double gloves; Fluid repellent disposable gown or suit; Plastic apron (over the disposable gown or suit) Disposable visor; FFP3 respirator or EN certified equivalent. Lead clinician should discuss urgently with the Consultant Microbiologist who will contact Public Health England and arrange for immediate transfer. Notify the infection prevention and control team of the positive VHF screen result; Launch full public health actions including formation of an Incident Control Team. If it is judged that the condition of the patient precludes transfer, an immediate discussion with the Consultant Microbiologist and the Infection Prevention and Control team should take place regarding local risk assessment and control measures. Clinical specimens Specimens must always be transported in person/courier Specimens should be discussed in advance between the consultant microbiologist, clinicians and the appropriate specialist for each laboratory area. During specimen collection, standard infection control principles and practices should always be adopted. In addition, staff must select PPE in accordance with the risk category of the patient Page 10 of 14
Low possibility of Viral haemorrhagic fevers Use standard precautions High Possibility of Viral haemorrhagic fevers Use Enhanced standard precautions Inform the laboratory Keep specimens to the minimum Specimens must be carried in a suitably sealed container and labelled with a Danger of Infection sticker Select PPE in accordance to the risk category Confirmed Viral haemorrhagic fevers Keep specimens to the minimum Inform the laboratory Specimens must be carried in a suitably sealed container and labelled with a Danger of Infection sticker Select PPE in accordance to the risk category 14. Cleaning Where there has been no obvious contamination by blood and or body fluids standard cleaning procedures apply. Where there is contamination the area must be cleaned using an appropriate concentration of Chlorine releasing agent as follows: For blood 10,000 ppm For other contamination 1000 ppm Toilets should be disinfected at least daily but preferably after each use with a concentration of 10,000 ppm Chlorine releasing agents. Staff carrying out cleaning must use the same level of PPE as other staff and must be trained in its use. This training will be provided if and when a suspected case occurs. The hospital in-house Deep Cleaning Team is able to clean up and decontaminate a cubicle or room in most circumstances. However, if a more thorough deep clean and decontamination is required there are specialist firms, which have been authorised by the Government Decontamination Service (GDS), can be contacted. See DoH Group 4 VHF Document for further details. Specialist Deep Cleaning The following are specialist private deep cleaning firms that have been approved by the Government Decontamination Service (GDS) Bioquell UK Ltd 52 Royce Close West Portway Andover Hampshire SP10 3TS Technical support T: +44 (0)1264 252 915 T: +44 (0)1264 561 009 Contact : www.bioquell.com OR Braemer Howells 08700 73 77 66 73 Nearest Location Liverpool. Page 11 of 14
15. Crockery and cutlery Disposable crockery and cutlery should be used and disposed of as category A waste 16. Linen and laundry Disposable laundry should be used. If this is not possible linen must not be sent to the laundry. It must be disposed of as category A waste. 17. Toilets Toilets and commodes should be disinfected with hypochlorite containing 10,000ppm available chlorine at least daily, preferably after each use, and upon patient discharge. For non-ambulant patients, disposable bedpans should be used and the contents to be solidified with high-absorbency gel and then autoclaved or incinerated. 18. Waste All waste from patients classified as a possibility of having a VHF infection should be treated as category B infectious waste (orange bag, double bagged). All waste from patients classified as a high possibility of having a VHF infection should be treated as category A infectious waste (yellow bag, double bagged) on the basis that it is known or suspected to be contaminated with pathogens presenting the most serious risk of infection. All relevant consignment and disposal forms must be completed by the Waste Manager prior to the waste being transported. 19. Sharps Waste. All Sharps waste must be placed and secured in a single use burn bin. 20. Transport of Suspected Viral haemorrhagic fevers patients South Staffordshire and Shropshire Healthcare Trust will only be expected to look after suspected Viral haemorrhagic fevers patients for a short period of time. These patients will be transferred by a specialised team ambulance to the local acute hospital as a suspect case. From there within 48 hours confirmed Viral haemorrhagic fevers patients would be transferred by specialist ambulance to either the Cat 4 VHF specialist High Level Isolation Unit (HLIU) at the Royal Free Hospital, London, or one of the other three Cat 3 VHF hospitals for ongoing treatment 21. What to do for patients in the community Individuals that telephone and report that they are unwell and have visited an affected area in the past 21 days AND report a fever of >37.5 C or fever within the past 24 hours should be advised to stay at home and contact their primary care clinician.. Page 12 of 14
The primary care clinician is responsible for ensuring they are referred appropriately to the local acute trust for review. This will include liaising with a local microbiology, virologist or infectious disease physician as above. Do not visit any patient who fits the above criteria, if you are already with the patient when they discuss the above symptoms inform the IPC team. Do not engage in any physical care if possible and leave the patient as soon as it is safe to do so. If a patient presents at a clinic, isolate in a room immediately, limit staff contact, contact the consultant microbiologist via Queens Hospital Burton switchboard on 01283 56633, Use appropriate level of PPE. 22. Assessment, categorisation and management of contacts The IPCT will determine who is/are responsible for the assessment, categorisation and management of contacts, and designate a Monitoring Officer to monitor the higher risk contacts and the follow up actions to be taken. Each potential contact should be individually assessed for risk of exposure and categorised according to categories listed in the table below: There should be no restrictions on work or movement for any contacts, unless disease compatible symptoms develop Risk Category Contact Actions No Risk (Category 1) Low Risk (Category 2) No direct contact with the patient or body Casual contact, e.g. sharing a room with the patient, without direct contact with body fluids or other potentially infectious material Direct contact with the patient e.g. Routine medical/nursing care, handling of clinical/laboratory specimens, but did not handle body fluids, and wore PPE appropriately. Reassure about absence of risk Reassure about low risk Passive monitoring Self monitor for fever and other disease compatible symptoms for 21 days from last possible exposure High Risk ( Category 3) Unprotected exposure of skin or mucous membranes to potentially infectious blood or body fluids; including on clothing and bedding. This includes: Unprotected handling of clinical/laboratory specimens Mucosal exposure to splashes Needle stick injury Kissing or sexual contact Report to monitoring officer if temperature >38.0c for further evaluation Inform about risks Active monitoring Record own temperature for 21 days following last contact with the patient and report to monitoring officer by 12 noon each day, with further evaluation as necessary. Inform Monitoring officer urgently if symptoms develop Page 13 of 14
23. External Contact List The on call Consultant Microbiologist Queens Hospital Burton Telephone: switchboard on 01283 566333 Public Health England. West Midlands North Health Protection Team Telephone: 0344 225 3560 Option 2, Option 2 Public Health England PHE Manor Farm Road Porton Down Salisbury Wiltshire SP4 0JG Telephone: 01980 612100 (24 Hour) Main Switchboard Telephone: 01980 612100 Clinical Commissioning Group (CCG) Southern Area Staffordshire Urgent Care Systems Management Team (During office hours) Chris Oliver Staffordshire Urgent Care Lead 07977 667797 Joy Everall Urgent Care Manager 07885 971785 Gaynor Duffell Administrator 01785 221033 First Responder On-Call (Out of Hours) Tel: 01384 679 035 24. Mortuary Arrangements The body of any patient who dies of suspected or confirmed Viral haemorrhagic fevers VHF will be placed in a special gas tight, spill proof body bag, which are available from West Midlands Ambulance. In the event of a pandemic temporary mortuary arrangements would be made 25. References Department of Health Management of Hazard Group 4 Viral Haemorrhagic Fevers and similar human infectious disease of high consequence Advisory Committee on Dangerous Pathogens August 2014. Public Health England - Viral haemorrhagic fevers virus disease: clinical management and guidance 20 th August 2014. Public Health England - Summary Guidance for Acute Trust Staff: Identifying and managing patients who require assessment for Viral haemorrhagic fevers virus disease 15 th August 2014. Page 14 of 14