Management of Viral Haemorrhagic Fevers Management of Viral Haemorrhagic Fevers Policy Author: Health Protection Team Responsible Lead Executive Director: Director of Public Health Endorsing Body: Health Protection Committee Governance or Assurance Committee Clinical Governance Committee Implementation Date: December 2014 Version Number: V 2.3 Review Date: November 2016 Responsible Person Josephine Pravinkumar Version No.2.3 December 2014 Page 1 of 35 Management of Viral Haemorrhagic Fevers CONTENTS i) Consultation and Distribution Record 10) Change Record 1. INTRODUCTION 2. AIM, PURPOSE AND OUTCOMES 3. SCOPE 4. PRINCIPLE CONTENT 5. ROLES AND RESPONSIBILITIES 6. RESOURCE IMPLICATIONS 7. COMMUNICATION PLAN 8. QUALITY IMPROVEMENT – MONITORING AND REVIEW 9. EQUALITY AND DIVERSITY IMPACT ASSESSMENT 10. REFERENCES Appendix 1: VHF decision making algorithm (Nov 2014) Appendix 2: Patient Pathway Appendix 3: Infection Control Precautions – VHF Appendix 4: Checklist for Consultant Microbiologists when alerted regarding the possibility of a patient with VHF Appendix 5: Protocol for Blood Sampling for Patients with Possibility of VHF Appendix 6: Categorisation and Management of Contacts Appendix 7: WHO (2014) Correct Method of putting on and removing PPE and HPS PPE Training Slides Appendix 8: Guidance for Waste Management Appendix 9: Contact Tracing Record Additional Documents for Reference: Ebola Clinical Guide Infographic Ebola and Infectivity Version No.2.3 December 2014 Page 2 of 35 Management of Viral Haemorrhagic Fevers CONSULTATION AND DISTRIBUTION RECORD Contributing Author / Authors Consultation Process / Stakeholders: Distribution: Lindsay Guthrie, Senior Nurse Health Protection Josephine Pravinkumar, Consultant Public Health Medicine Biochemistry laboratory staff Consultant Microbiologist Emergency Department consultant and Receiving Units General Practitioners (GP) Haematologists Infection control staff Infectious Diseases (ID) consultant & ID Unit staff Mortuary staff PSSD Public Health Salus Scottish Ambulance Service NHS Lanarkshire intranet – Firstport NHS Lanarkshire internet CHANGE RECORD Date 22/11/2013 10/02/2014 18/03/2014 20/03/2014 Author Lindsay Guthrie Lindsay Guthrie Lindsay Guthrie Lindsay Guthrie 01/04/2014 Lindsay Guthrie 28/04/2014 Lindsay Guthrie 17/07/2014 Lindsay Guthrie 28/08/2014 Josephine Pravinkumar 10/09/2014 Lindsay Guthrie 09/10/2014 Lindsay Guthrie 14/10/2014 Josephine Pravinkumar 17/10/2014 L Guthrie 12/11/2014 L Guthrie / J Pravinkumar 28/11/2014 J Pravinkumar 23/12/2014 J Pravinkumar Version No.2.3 Change Content revised to reflect DoH guidance Final version for approval Updated to reflect updated ACDP guidance Updated to reflect Laboratory comments & updated guidance Final version for approval Updated to reflect SAS VHF policy – change to information re transfer of patients Updated to reflect updated HPS algorithm Updated to reflect updated ACDP guidance Version No. V0.2 V1.0 V1.1 V1.2 Updated to reflect revised guidance Updated algorithm, guidance and to reflect comments from of table top exercise Updated guidance to reflect comments from ID unit staff and exercise participants Interim version with further changes Updated version to reflect national guidance and local discussion and arrangements Updated to reflect ACDP guidance Updated to reflect local arrangements V1.7 V1.8 & 1.9 December 2014 V1.3 V1.4 V1.5 V1.6 V1.10 V2.0 V2.1 V2.2 V2.3 Page 3 of 35 Management of Viral Haemorrhagic Fevers 1. INTRODUCTION This policy has been developed for use in NHS Lanarkshire as part of the Control of Infection policy manual. This policy should be read in conjunction with the following policy: Section 1 – Standard Infection Control Precautions 2. AIM, PURPOSE & OUTCOME To ensure that healthcare workers (HCWs) consider Viral Haemorrhagic Fever (VHF) as a possible diagnosis in patients with an indicative history and symptoms. To ensure that all HCWs take appropriate actions to minimise the risk of cross infection to themselves and others by urgent and appropriate referral in line with the guidance developed by the Department of Health. To ensure that all HCWs apply appropriate infection prevention and control precautions when providing care for patients with suspected or known infection with VHF. 3. 1 SCOPE This policy is designed to safeguard patients, staff and the wider public from the risk of VHF. The policy is aimed at healthcare staff working in NHS Lanarkshire, but particularly 3.2 Emergency Department staff Out of hours services General Practitioners Infectious diseases unit staff Laboratory staff Public Health professionals Mortuary and funeral services staff STAKEHOLDERS Infectious Diseases Unit Emergency Departments Consultant Microbiologist Infection Control Staff Department of Public Health General Practitioners PSSD Mortuary staff Scottish Ambulance Service Salus Version No.2.3 December 2014 Page 4 of 35 Management of Viral Haemorrhagic Fevers 4.1 VIRAL HAEMORRHAGIC FEVERS Viral Haemorrhagic fevers (VHF) are severe and life threatening diseases caused by a range of viruses. They are endemic in some parts of the world, particularly: Africa South America Middle East, and Eastern Europe. VHFs are of particular public health importance because: they can spread within a hospital setting they have a high case-fatality rate they are difficult to recognise and detect rapidly, and there is no effective treatment. Causative organisms Clinical manifestation Incubation period Period of infectivity Mode of transmission Reservoirs Population at risk Notifiable disease Version No.2.3 Of 15 viral agents, 4 are more commonly known: Ebola (Filoviridae) Lassa (Arenaviridae) Crimean/Congo haemorrhagic fever caused by Nairovirus (Bunyaviridae) and Marburg Fever, headache, myalgia, pharyngitis, diarrhoea, vomiting, macropapular rash, bruising, bleeding, multi organ failure Up to 21 days (dependent on virus) Can be up to 61 days post onset Experimental evidence suggests that the virus can survive on surfaces in lower temperatures for over three weeks People remain infectious as long as their blood and body fluids, including semen and breast milk, contain the virus e.g. for up to 7 weeks after recovery from illness Direct contact (through broken skin or mucous membrane) with blood or body fluids, and Indirect contact with environments contaminated with splashes or droplets of blood or body fluids There is no evidence of an aerosol transmission risk from VHF patients Exposure to patients prior to the onset of fever does not appear to carry the risk of transmission Bite of an infected tick or mosquito Animal/insect hosts No natural environmental reservoirs in UK Secondary infection risk from exposure to infected blood or body fluid Travellers, healthcare workers, laboratory staff All recorded cases of VHF in the UK have been acquired abroad, with the exception of one laboratory worker who sustained a needle-stick injury. Yes December 2014 Page 5 of 35 Management of Viral Haemorrhagic Fevers 4.2 PATIENT RISK ASSESSMENT A risk assessment of exposure to biological agents is a legal obligation under the Control of Substances Hazardous to Health (CoSHH) Regulations. It is the responsibility of the general practitioner, or admitting physician to recognise the risk of VHF. VHF infection is possible in any patient presenting with: a fever of unknown origin, or a history of fever within previous 24 hours, AND a travel history or epidemiological exposure within 21 days Other symptoms of concern would be: bruising or bleeding, uncontrolled diarrhoea or vomiting. When assessing a patient with fever who has a history suggestive of VHF, it is difficult to make a firm diagnosis solely on clinical grounds, therefore attention must be paid to epidemiological evidence e.g. travel to endemic areas, association with any known cases. A possible VHF case must fulfil the following conditions: A) The patient has a fever or history of fever in past 24 hours AND has returned from a VHF affected area or endemic country within 21 days OR B) The patient has a fever or history of fever in past 24 hours AND has cared for / come into contact with body fluids of / handled clinical specimens (blood, urine, faeces, tissues, laboratory cultures) from an individual or laboratory animal known or strongly suspected to have VHF? If any of the above conditions are fulfilled secure answers to the following questions: 1) Patient travelled to Guinea, Liberia, Sierra Leone, Mali, Congo DR or other countries where cases of Ebola / VHF have been reported during past 21 days? 2) Lived or worked in basic rural conditions? 3) Visited caves OR mines, or had contact with or eaten primates, antelopes or bats? 4) Sustained a tick bite, crushed a tick OR had close involvement with animal slaughter? If none of the four above apply AND the patient has no history of bruising, active bleeding, vomiting or diarrhoea, then there is a LOW POSSIBILITY OF VHF. To assist clinical decision making, please see: APPENDIX 1 – VHF Risk Assessment Algorithm For up to date information on VHF risk maps see: Travax and WHO Ebola Response Roadmap Version No.2.3 December 2014 Page 6 of 35 Management of Viral Haemorrhagic Fevers Following initial assessment, and where VHF is considered, formal risk assessment MUST be carried out by the on-call Consultant Infectious Diseases (ID) physician [Contact via Monklands General Hospital switchboard: Telephone 01236 748 748] Following this assessment, patients will be classified as: Unlikely to have a VHF – answers no to questions A & B on page 6 N.B. With this classification, a patient is no longer suspected of having VHF, and as such additional PPE and patient isolation are no longer required (unless they are needed for other clinical reasons). There is also no need for a VHF laboratory communication cascade or a teleconference with the Scottish Ambulance Service. However, if the patient’s risk classification is ever upgraded to “Low Possibility” or “High Possibility”, then the appropriate guidance as shown in this document should be followed. An example where this may occur is when an individual is initially asymptomatic after returning from a VHF endemic country, therefore is “unlikely to have a VHF”, but subsequently becomes symptomatic. Low Possibility – (1) answers yes to question A, but (2) answers no to question B and all stated additional questions and (3) does not have extensive bruising or active bleeding. High possibility – (1) answers yes to question B, or (2) answers yes to question A and any additional question (3) and/ or has extensive bruising or active bleeding. Confirmed VHF – any patient with a positive VHF screen A patient pathway is available as Appendix 2 to help determine the initial actions and precautions required to safely manage patient care and minimise the risk of infection to staff and the wider population. A sample contact tracing form is available as Appendix 9 to record list of contacts that may have been inadvertently exposed to a high possibility case. The Consultant Microbiologist will liaise with the Imported Fever Service at Public Health England to discuss VHF screening as appropriate: Telephone 0844 7788990. From 1st December 2014, a Scottish VHF testing service is available for testing samples of “high possibility of VHF” using molecular (real time PCR) approaches. A checklist summarising the actions for Consultant Microbiologists is available as Appendix 4. 4.2.1 MANAGEMENT OF PATIENT IN PRIMARY CARE All suspected Ebola cases that present to primary care should be discussed with the ID Consultant who will lead the risk assessment and arrange clinical review. Individuals that telephone the surgery or walk-in centre and report that they are unwell and have visited an affected area in the past 21 days must be told not to visit the surgery or walk-in centre. The patient should be called back as soon as possible by the GP or duty doctor to risk assess prior to discussion with the ID Consultant. Version No.2.3 December 2014 Page 7 of 35 Management of Viral Haemorrhagic Fevers Surgeries, out of hours’ centres and walk in centres should clearly display information requesting patients to tell the receptionist on arrival if they are unwell and have returned from an Ebola-affected area within the last 21 days. Any patients identifying themselves to reception staff should not sit in the general waiting room once Ebola is considered a possibility. These patients should be isolated in a single side room immediately to limit contact, and urgent clinical advice sought from the ID Consultant. If at the time of a consultation it becomes apparent that Ebola may be a possibility then the attending primary care clinician should take immediate steps to isolate the patient to limit further contact and seek advice from the ID Consultant. Hand hygiene is an important infection control measure; the Ebola virus is not a robust virus, and is readily inactivated, for example, by soap and water or by alcohol. It is important to remember that transmission of Ebola from person to person is only through direct contact with the blood or body fluids of a symptomatic infected person. There is no evidence of Ebola transmission through intact skin or through small droplet spread, such as coughing or sneezing. Cleaning and decontamination of any rooms in which a suspected or confirmed Ebola patient has been isolated or any facilities used by the patient should be discussed with the local Health Protection Team. Further information for GP practices can be found on the Health Protection Team Firstport page. 4.3 PATIENT MANAGMENT – INFECTION PREVENTION AND CONTROL It is assumed that ALL STAFF will observe standard infection control precautions (SICPs) at ALL TIMES with ALL PATIENTS, to minimise the risk of infection to staff and other patients. In addition to standard precautions, staff should also be familiar with, and practice the following Transmission Based Precautions (TBPs): Contact precautions Droplet precautions Airborne precautions Personal Protective Equipment (PPE) must be worn by all staff caring for suspected VHF patients. This PPE must establish a barrier against contact with contaminated surfaces, splash, spray, bulk fluids and aerosol particles. It must also cover all exposed skin with sufficient integrity to prevent any ingress or seepage of liquids or airborne particles. Please see Appendix 3 for detailed advice on the infection control precautions required. Additional Information for Reference Version No.2.3 December 2014 Page 8 of 35 Management of Viral Haemorrhagic Fevers Appendix 7 - WHO (2014) Correct Method of putting on and removing PPE and HPS PPE Training Slides Appendix 8 - Waste Management Guidance Version No.2.3 December 2014 Page 9 of 35 Management of Viral Haemorrhagic Fevers 4.4 SPECIMEN HANDLING & LABORATORY PROCEDURE To minimise the risk of contamination to staff and patients, point of care/near patient testing equipment (e.g. blood gas analysers) should not be used to process samples from patients who are being assessed for VHF. The only exception to this is blood glucose (capillary testing) testing for diabetics. All samples should be sent to the appropriate laboratories for processing and the laboratory staff advised, before sending samples, of a possible diagnosis of VHF. The receiving laboratory should telephone the ward to confirm receipt of samples. Specimens from patients who have a high possibility of confirmed VHF should only be requested following discussion with the ID Consultant. Routine biochemistry/haematology tests can be taken and sent (with prior notification) to the laboratories whilst awaiting the outcome of the malaria film. Test Highly possibility of VHF (with: bleeding bruising and/or uncontrolled vomiting or diarrhoea) URGENTLY – Should only be undertaken in the Class 1 Safety cabinet within lab Confirmed case of VHF VHF Screening Discuss with ID Consultant if malaria negative with continuing fever Discuss with ID Consultant if malaria negative Urgent VHF screening AFTER discussion with ID consultant N/A Routine laboratory diagnostic tests (suggested) Full blood count Full blood count Full blood count U&Es U&Es U&Es LFTs LFTs LFTs Glucose Clotting screen Clotting screen Patient would be transferred to the HLIU where further testing would be undertaken CRP CRP CRP Clotting screen Glucose Glucose Blood culture Blood culture Blood culture Malarial screen Note: Glucose measurement may be performed on the same yellow top tube being sent for U&E, CRP and LFT tests, and a separate grey top tube will not be required Low possibility of VHF Highly possibility of VHF N/A Stool culture Urine culture Version No.2.3 December 2014 Page 10 of 35 Management of Viral Haemorrhagic Fevers To minimise the risk to staff, the following must be observed: Laboratory staff MUST be informed of specimens BEFORE THEY ARE SENT Specimen handling and storage should be kept to a minimum Vacutainer system must be used All specimens from cases with a high possibility of VHF must be appropriately labelled, double bagged and placed into a rigid PVC container (i.e. a bio bottle within an appropriate cardboard box) ¹ (obtained from the laboratory) for transport from the Emergency Department / ward to the laboratory Pneumatic tube system must not be used for the transport of samples to the laboratory Strict adherence to standard infection control precautions and laboratory procedures by all staff at all times. Clinical staff MUST inform the laboratory if the patient risk category changes during the period of admission. Specimen handling for VHF investigations Non essential samples (urine, stool and sputum) will only be processed after discussion between Consultant Microbiologist and Infectious Diseases (ID) Consultant. It has been agreed that patients with a high possibility of VHF should receive unmatched Group O Rh (D) Negative red cells and Group AB FFP/CRYO without any pre-transfusion serological testing if their clinical situation demands transfusion support. Samples must be transported to the laboratory by clinical staff and handled directly to the Microbiology BMS staff to the named person expecting the sample No samples should be left unattended in the Laboratory reception All samples must be processed in the Category 3 Containment Laboratory Laboratory forms must accompany the specimen to the category 3 laboratory. Data entry into the Laboratory Information System must be performed in Category 3. No forms should be scanned or leave the Category 3 facility Blood tubes or blood culture bottles that are visibly contaminated with blood or are leaking will not be accepted and repeat samples will be required Visibly soiled forms should not be accepted and the ward should inform to provide a repeat form asap Appropriate disinfection of sample containers should be performed prior to handling the sample. Containers and left over sample must be disposed as hazardous waste and incineration and autoclave. Samples should not be kept after processing Appropriate PPE must be used in accordance with the laboratory Standard Operating Procedure. Adherence to the NHSL Standard Operating Procedure (SOP): Guidelines for Processing Samples Potentially Infected with Viral Haemorrhagic Fever is expected when handling Version No.2.3 December 2014 Page 11 of 35 Management of Viral Haemorrhagic Fevers samples from these patients. Use of personal protective equipment (PPE) in accordance with the SOP is required when processing specimens. ¹ Rigid PVC UN marked container which meets the standard required by The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009 Appendix 5 provides a summary of the steps involved in taking blood samples from patients with a possibility of VHF. Retrieval of specimens If the possibility of VHF is realised after specimens have been sent, it is the responsibility of the Consultant Microbiologist to ensure that specimens are: Located quickly Made safe by autoclaving and incineration (Category A waste). OR If not for immediate disposal, packed in rigid containers, which should be surface decontaminated and retained within the laboratory awaiting safe disposal 4.5 VHF LABORATORY COMMUNICATION CASCADE The ID Consultant in charge of the patient will contact the Consultant Microbiologist to inform of the possibility of VHF. The Consultant Microbiologist will cascade this information to the relevant Consultant Biochemist and Haematologist to alert them. On- call Microbiologist (notified by ID Consultant) On- call Microbiology BMS On-call Consultant Biochemist On- call Consultant Haematologist Microbiology safety officer (if required) On- call Biochemistry BMS On- call Haematology BMS 2nd On-call Haematology BMS 4.6 PATIENT TRANSPORT GPs should not use 999 ambulance services to arrange hospital transfer of patients from the community. The Infectious Disease Consultant will arrange, with the SAS, for the transfer of any patients who are suspected of being infected with VHF. VHFs are classified as Ambulance Category 4 infectious diseases across all Ambulance Services in the UK. Version No.2.3 December 2014 Page 12 of 35 Management of Viral Haemorrhagic Fevers Therefore, patients categorised as ‘low possibility’; ‘high possibility’ or ‘confirmed’ will require to be transferred in accordance with Scottish Ambulance Service (SAS) protocols. Only staff who have received specialist training are permitted to transport these cases. Ambulance control will coordinate the Special Operations Response Team (SORT). The decision to transfer a patient should be made by the Consultant in Infectious Diseases. Transfer to any unit outwith NHS Lanarkshire (e.g. Royal Free Hospital London High Level Isolation Unit (HLIU) will only be arranged following consultation and agreement with referring clinician or clinicians at the HLIU/other unit to which the patient is to be transferred. Consultant ID Call ambulance control - request ‘National Operations Manager’ Rapid teleconference - ID consultant/SAS/ referring doctor (+/CPHM - discuss patient risk category, medical and other requirements Special operations response team (SORT) team mobilised with 2 nd team following as back up. The ID Consultant is responsible for liaising with SAS to arrange emergency tertiary referral to the Royal Free Hospital, London HLIU. If an isolator is required (for confirmed cases) SAS SORT will liaise with North East Ambulance Service or London Ambulance Service to coordinate the provision of this. Transfer of a patient within the UK to an HLIU may be necessary when either: the patient has had a positive VHF screen result, OR the patient has been categorised as ‘high possibility of VHF’, AND has bruising or bleeding, OR uncontrolled diarrhoea or uncontrolled vomiting. The Director of Public Health of the patient’s health board of residence and the Scottish Government Health Department must be informed promptly of referral to the Royal Free Hospital, London HLIU. 4.6.1 INTERNAL TRANSFER OF PATIENTS Patients admitted via the Emergency Department may be required to be transferred internally to Ward 2 (MGH) Infectious Diseases Unit following the NHS Lanarkshire radiation procedure. Version No.2.3 December 2014 Page 13 of 35 Management of Viral Haemorrhagic Fevers 4.7 LAST OFFICES, POST MORTEM & GUIDANCE FOR FUNERAL STAFF Post Mortem: A post mortem examination on a person known to have died of VHF exposes staff to an unwarranted risk and should NOT be performed. Removal of pacemakers or implants should only be undertaken following discussion and agreement with the CPHM Body preparation/last offices: Hygienic preparation and embalming on a patient known to have died of VHF exposes staff to an unwarranted risk and should NOT be performed. Viewing of the deceased should be avoided. Where the body of a confirmed or suspected VHF patient is not in an isolator, staff wearing suitable PPE should place the body inside double-sealable leak-proof body bag, with absorbent material between each bag. Absorbent material should be placed between each bag, and the bag sealed and disinfected with 1000ppm available chlorine or other appropriate disinfectant. The bag should be labelled as high risk of infection The body bag should be placed in robust coffin with sealed joints. Post mortem examinations should not be performed Blood sampling can be undertaken by a competent person to confirm or exclude VHF diagnosis An infection control notification sheet should be completed for the funeral director (section O of CIM) Specific guidance for undertakers The person in charge of the mortuary has a statutory duty to protect people coming into contact with infected bodies, and family and funeral directors must be informed of the infection risk. The body bag/coffin must not be opened except if authorised by the Consultant in Public Health Medicine (CPHM), and then only by a person designated by them. Transportation of the body out of the country is not recommended. Following cremation, ashes may be safely transported. In the unlikely event of a VHF infected body being embalmed abroad and transported back to the UK, it would need to be contained within a sealed zinc lined transport coffin in accordance with International Air Transport Association IATA requirements. Return of personal effects Version No.2.3 December 2014 Page 14 of 35 Management of Viral Haemorrhagic Fevers The family of the deceased should be consulted and, as far as is reasonably practicable, their needs and wishes should be respected. In principle; clothing, personal effects and valuables may be returned to relatives in accordance with normal health service procedure following decontamination. Items of clothing visibly contaminated should be safely disposed of. Other items of clothing should be autoclaved prior to laundering. Wedding rings, jewellery and other physical artefacts should either be autoclaved or decontaminated using a validated disinfectant. With sensitivity and respect for the dignity of the bereaved, relatives should be alerted that some clothing fabrics and materials from which personal effects are made (e.g. plastics) may be adversely affected or even destroyed by autoclaving or disinfection (hypochlorite, the disinfectant of choice is a powerful bleach). In such cases, with the agreement of relatives, subsequent disposal may be the preferred option. 4.8 COMMUNICATION CASCADE Any possible, highly possible or confirmed case of VHF must be notified to the Consultant in Public Health Medicine (CPHM) without delay. The On- Call CPHM will issue a communication cascade to relevant clinical and management colleagues about a possible diagnosis of VHF. If transfer of the patient is likely, early communication with Scottish Ambulance Service is required. Following notification, a teleconference will be arranged to discuss the risk assessment and clinical requirements for transfer. Specialty Infectious Diseases Consultant Location Monklands General Hospital Telephone number 01236 748 748 Consultant Public Health Medicine (Health Protection) Kirklands (during working hours) 01698 858 232 On Call Consultant Public Health Medicine Consultant Microbiologist Via switchboard Monklands General Hospital Monklands General Hospital 01236 748 748 Wishaw General Hospital 01698 361 100 Hairmyres General Hospital 01355 585 000 Imported Fever Service 0844 7788 990 Duty Consultant Rare and Imported Pathogens Laboratory (if above number not available) West of Scotland Control 01980 612100 (24hr) Public Health England (previously HPA) Scottish Ambulance Service Version No.2.3 December 2014 01236 748 748 03333 990125 (24 hrs) Page 15 of 35 Management of Viral Haemorrhagic Fevers Centre (ask for duty manager) 0345 123999 (24 hrs) High Level Isolation unit (HLIU) Air Ambulance Royal Free Hospital , London 0844 8480700 (local rate from outside London) OR: 020 7794 0500 Switchboard – 24 hrs ask for ID Consultant on call NHS Lanarkshire Procurement Hairmyres Hospital IPCT Contact Number (s) Kirklands Hospital 01355 584956 (during working hours) 01698 858254 (during working hours) 4.10 PUBLIC HEALTH MANAGEMENT On notification of any confirmed case of VHF, the duty Consultant in Public Health Medicine will convene and chair an Incident Management team (IMT). An IMT may also be considered for managing high possibility cases. The CPHM or Director of Public Health must notify HPS and the Chief Medical Officer’s team in the Scottish Government. Using the Hospital Infection incident Assessment Tool (HIIAT) potential cases should be categorised as: Low possibility of VHF- AMBER High possibility of VHF (with or without bleeding etc) –RED Confirmed case of VHF - RED The ‘Management of Public Health Incidents Plan’ will be activated. Core membership of the IMT will include: CPHM Health Protection Nurse Consultant in Infectious Diseases Consultant Microbiologist/Infection Control Doctor Scottish Ambulance Service Infection Control Nurse Consultant in Occupational Health Medicine Administrative support Communications officer Other persons may be co-opted at the discretion of the IMT. Members of the IMT will be responsible for briefing other members of their organisation as appropriate. Version No.2.3 December 2014 Page 16 of 35 Management of Viral Haemorrhagic Fevers Key Actions of the IMT: Identify, assess and categorise contacts Arrange advice and reassurance to contacts Ensure appropriate monitoring of higher risk contacts Arrange further evaluation of contacts who develop symptoms To consider antiviral prophylaxis, and arrange as necessary Review patient management including provision of post recovery advice Review control measures Prepare advice for general public Prepare briefing for professionals including Scottish Government 4.10.1 Management of Staff accidentally exposed to potentially infectious material Any staff member who is exposed to, or sustains an injury with potential for exposure to, blood or body fluids in high possibility or confirmed cases of VHF must: Take immediate first aid in line with current policy (e.g. needlestick injury) Wash the affected area soap and running water Irrigate mucous membranes with emergency wash bottles All such exposures must be reported without delay to the Consultant in Infectious Diseases, Infection Control Doctor and SALUS Occupational Health & Safety. A DATIX form should be completed as per policy for any blood or body fluid exposure incident. If VHF is subsequently confirmed in the source patient, the incident must be reported under Reporting of Injuries, Diseases, and Dangerous Occurrences Regulations 2013 (RIDDOR). The exposed individual must be followed up as a High Risk contact (Category 3) see Appendix 6. 5. ROLES AND RESPONSIBILITIES All staff are responsible for implementing and following the information provided in this policy. 6. RESOURCE IMPLICATIONS There are implications for additional cost associated with: Additional PPE Laboratory costs (including staffing) Transport costs (cost of transporting Category 4 samples to specialist laboratory, internal transfer NHS Lanarkshire, external transfer to HLIU) Waste disposal costs (incineration) Additional consumables Version No.2.3 December 2014 Page 17 of 35 Management of Viral Haemorrhagic Fevers 7. COMMUNICATION PLAN This policy is available on NHS Lanarkshire intranet. Changes to policy or guidance will be communicated to key personnel via: Email Discussion at departmental meetings Note on staff briefing on First Port Educational sessions 8. QUALITY IMPROVEMENT Compliance with this policy will be monitored by the Infection Control Team. 9. EQUALITY & DIVERSITY ASSESSMENT √ This policy meets NHS Lanarkshire’s EDIA (tick box) 10. Frequently Asked Questions (FAQs) If you have any questions about this policy or how to implement it, please contact the Infection Control team/Health Protection Team to discuss your query. A list of FAQs is available on the Health Protection Team page on Firstport: http://firstport2/staff-support/public-health/health-protectionteam/Latest%20Topic/FAQs.pdf 11. REFERENCES Department of Health (2014) Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious disease of high consequence(Sept 2014) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/354640/VHF _guidance_document_updated_links.pdf HPS (2014) Advice for Purchase of Required PPE for Viral Haemorrhagic Fever (VHF) preparedness http://www.documents.hps.scot.nhs.uk/travel/vhf/vhf-ppe-purchasing-v2.0.pdf RCPath (2014) Autopsy in patients with confirmed or suspected Ebola virus http://www.rcpath.org/Resources/RCPath/Migrated%20Resources/Documents/P/PUBS_E bolaAutopsy_Sept14_V2.pdf Scottish Ambulance Service (2014) -HS003t – Hazard Group 4 Viral Haemorrhagic Fevers & Similar Infectious Diseases of High Consequence http://www.documents.hps.scot.nhs.uk/travel/vhf/vhf-transportation-patient-v1.2.pdf Version No.2.3 December 2014 Page 18 of 35 Management of Viral Haemorrhagic Fevers HPS (2014) VHF information pages http://www.hps.scot.nhs.uk/travel/viralhaemorrhagicfever.aspx World Health Organisation (2014) Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in HealthCare Settings, with Focus on Ebola http://apps.who.int/iris/bitstream/10665/130596/1/WHO_HIS_SDS_2014.4_eng.pdf?ua=1& ua=1&ua=1 For Additional Information see Scottish Supplement to ACDP Guidance: http://www.documents.hps.scot.nhs.uk/travel/VHF/ebola-scottish-supplement-nov2014.pdf Version No.2.3 December 2014 Page 19 of 35 Management of Viral Haemorrhagic Fevers Appendix 1 – VHF decision making algorithm (Nov 2014) Version No.2.3 December 2014 Page 20 of 35 Management of Viral Haemorrhagic Fevers Appendix 2: Patient Pathway GP or Out of hours staff identify possible VHF case A&E or Receiving Unit staff identify possible VHF case Patient with: Fever or history of fever Travel in past 3 weeks to o Guinea, o Liberia, o Mali o Congo DR, o Sierra Leone Or any other location where outbreak reported Patient with: Fever Cared for/contact with blood or body fluid of known or suspected VHF case (human or animal) Lived or worked in basic rural conditions? Visited caves/mines? Contact with primates/antelopes/bats? Sustained a tick bite? Close involvement in animal slaughter? Isolate patient – limit further staff contact Version No.2.3 December 2014 Provide contact list to CPHM/ ID Consultant YES Patient is at GP practice/in hospital? NO GP/Hospital clinician to notify on-call ID Consultant* / Paediatric Consultant who will lead the risk assessment VHF still actively considered? NO Patient with: Fever Travel in past 3 weeks to a VHF affected area or endemic country GP/Hospital clinician to compile list of contacts ID / Paediatric Consultant to provide GP with advice on patient management as per standard referral pathway for managing febrile travellers – malaria needs to be excluded Page 21 of 35 GP/ Hospital Clinician or ID Consultant to notify CPHM YES *If Ebola is suspected in a pregnant woman, the on call Consultant Obstetrician should be involved in the risk assessment and clinical management ID / Paediatric Consultant liaise with SAS to arrange patient transport & admission to Monklands Hospital ward 2/ local or regional Paediatric ward (Patient must not use public transport) Arrange admission to hospital if clinically indicated- standard referral pathway Arrange urgent Malaria Screen Management of Viral Haemorrhagic Fevers Appendix 3: Infection Control Precautions – VHF (adapted from HPS VHF Infection Prevention & Control precautions summary version 2.0) Control Measure Low possibility case High Possibility case Confirmed VHF case Criteria The patient has no bleeding/bruising or uncontrolled vomiting or diarrhoea The patient is categorised as High Possibility of VHF – may or may not be bleeding/ have uncontrolled vomiting or diarrhoea The patient has a positive VHF test and may or may not be bleeding/ have uncontrolled vomiting or diarrhoea Isolate immediately in single room with ensuite or dedicated commode Isolate immediately in single room (Negative pressure and ante room where possible) with en-suite or dedicated commode Isolate immediately in negative pressure isolation room with ante-room and en-suite or dedicated commode OR AND AND ID Consultant to arrange transfer to ID unit Monklands General hospital if clinically appropriate ID Consultant to arrange transfer to ID unit Monklands General hospital if clinically appropriate ID Consultant to arrange urgent transfer to HLIU at Royal Free Hospital, London if clinically appropriate (if bruising/bleeding/vomiting/diarrhoea – manage as High Possibility for VHF) Patient placement (Accommodation) OR ID Consultant to arrange urgent transfer to High Level Isolation Unit (HLIU) –Royal Free Hospital, London if clinically appropriate Staffing/contact with people Limit contact with other people Clinical staff only (no domestics etc) - Clinical staff to perform routine cleaning Limit the number of HCWs who come into contact with the patient Keep up to date list of staff who enter the room and who have been in contact with the patient throughout their care for possible contact assessment. Restrict non-essential personnel and visitors from the patient care area. Version No.2.3 December 2014 Page 22 of 35 Control Measure Management of Viral Haemorrhagic Fevers Low possibility case High Possibility case Confirmed VHF case Moving patient between wards and departments As per standard hospital procedures Do not transfer unless under direct supervision of ID Consultant/IPCT PPE For all contact: Standard uniform Disposable surgical apron (green) Disposable clinical gloves Standard footwear (as per dress code) PPE must cover all exposed skin with sufficient integrity to prevent ingress or seepage of liquids or airborne particles If risk of splashing, add: Disposable full face visor OR Half face fluid shield visor mask OR Goggles and fluid repellent surgical face mask For all contact: Replace uniform with theatre scrubs Fluid repellent coverall with hood Disposable surgical (green) apron FFP3 mask Disposable full face visor/face shield Double surgical (gauntlet type) gloves (glove to overlap wrist cuff) Wellington Boots with over boots If vomiting/bleeding/bruising present – adopt PPE as for high possibility case until VHF screen negative Aerosol Generating Procedures (AGPs) Avoid AGPs unless clinically necessary. For AGPs in any category of patient: Full PPE as for High Possibility case including FFP3 respirator. Hand hygiene As per SICPs Hand washing with soap and water after removing PPE Waste Treat ALL waste as clinical – dispose of into ORANGE bags (Category B waste) All waste for incineration – Double YELLOW bags³ (Category A waste) Sharps waste – YELLOW box & YELLOW lid Sharps waste – YELLOW box & ORANGE lid Version No.2.3 December 2014 Hold in safe area until special uplift for incineration/autoclave Page 23 of 35 Control Measure Linen Equipment Management of Viral Haemorrhagic Fevers Low possibility case High Possibility case Reusable linen- treat any linen visibly contaminated with blood or body fluids as disposable (high risk- YELLOW waste bag). Confirmed VHF case All reusable linen must be disposed of into YELLOW waste bags Disposable linen should be considered If no visible contamination, use alginate bag & red bag as per SCIPs *Do not store supplies inside room* *Do not remove any equipment from the patient room without permission of the ICT* Single use equipment(including BP cuffs, stethoscopes, thermometers, washbowls) Needle free IV systems Disposable crockery & cutlery (High possibility/confirmed case only) – dispose of into YELLOW waste³ Dedicated commode (if required) – use disposable liner. Solidify all content using granules. Dispose of content into double YELLOW disposable waste bags³ (DO NOT MACERATE CONTENT) Cleaning & decontamination Toilet/commode: clean with 10,000ppm av. Chlorine after each use Decontamination of room & equipment: use disposable equipment where possible. Clean all surfaces with 1,000ppm av. Chlorine at least daily Terminal cleaning: clean with 1,000ppm av. Chlorine. If VHF confirmed, room fumigation required on discharge or death. Leave decontaminated equipment in room until fumigation process complete. Mattress: clean and check as per local policy. If VHF confirmed, dispose of as waste for incineration. Blood & body fluid spillage *All spills of blood/body fluid in ANY patient being assessed or treated for VHF should be treated as high risk for VHF*. Use full PPE as for high risk of VHF (fluid repellent coverall, wellington boots, face/eye protection) Blood: 10,000ppm av. Chlorine (contact time 3 minutes) Urine: solidify content, dispose of as Category A waste (Yellow bag) – apply 10,000ppm av. Chlorine (contact time 3 minutes). Version No.2.3 December 2014 Page 24 of 35 Control Measure Management of occupational exposure Management of Viral Haemorrhagic Fevers Low possibility case High Possibility case Follow SICPS - take immediate steps for First Aid Confirmed VHF case Follow SICPS – take immediate steps for First Aid. Report and refer urgently to Clinical Microbiologist, ID Consultant and SALUS. Provide reassurance & confirm when stand down that exposure was not to VHF Provide reassurance & confirm when stand down that exposure was not to VHF OR If VHF confirmed in source patient – Manager must report as a RIDDOR event. Full support for staff member & family throughout incubation period Ongoing assessment Monitor temperature Monitor for bleeding, bruising, diarrhoea and/or vomiting If symptoms appear – treat as high possibility of VHF until VHF screen negative Stand down (discontinue precautions) If Malaria negative and apyrexial and no other diagnosis – ID Consultant to discuss with Imported Fever Service If Malaria negative and Apyrexial and no other diagnosis – discuss with Imported Fever Service When ID Consultant confirms: VHF negative Responding to treatment (alternate diagnosis) Apyrexial for 24hours On patient discharge or death. (ID Consultant to discuss High Possibility cases with Imported Fever Service for other diagnosis) Version No.2.3 December 2014 Page 25 of 35 Management of Viral Haemorrhagic Fevers Appendix 4 – Checklist for Consultant Microbiologists when alerted regarding the possibility of a patient with VHF CHI number:_________________________ Date:___________________ 1. Discussion with Infectious Diseases (ID) Consultant 2. Risk assessment by ID physician: a. VHF unlikely b. Low possibility of VHF c. High possibility of VHF d. Confirmed VHF 3. Agreement on performing minimum investigations: a. Blood cultures b. Malaria film c. FBC, U&Es, LFTs, clotting, CRP, glucose 4. Inform duty Consultant Haematologist 5. Inform duty Consultant Biochemist 6. Inform Senior Biomedical scientist in Microbiology 7. Ensure all samples are handled in Category 3 containment level and adequate personal protective equipment is used 8. Arrange VHF screen with Imported Fever Service (08447788990) 9. Inform colleague Consultant Microbiologists at other sites 10. Processing of other samples out with those described above only after discussion with Consultant ID physician 11. Ensure transport of VHF screen sample is performed in accordance with current guidance 12. Reference Laboratory result of VHF screen to be telephoned to the ward as soon as possible 13. Have any samples of blood, urine, stool been already sent inadvertently from the patient in question: a. No b. Yes: i. Contact the relevant specialty (haematology/biochemistry) and ensure samples are retrieved appropriately and quarantined, samples must be disposed in accordance to the SOP Version No.2.3 December 2014 Page 26 of 35 Management of Viral Haemorrhagic Fevers After results from VHF screen are known, has the patient being confirmed as Positive Negative 14. If Negative, inform: a. Microbiology BMS staff so that precautions can be relaxed b. Haematology Consultant c. Biochemistry Consultant 15. If Positive-Confirmed all samples must continue to be processed in Containment level Category 3 Version No.2.3 December 2014 Page 27 of 35 Management of Viral Haemorrhagic Fevers Appendix 5 - Protocol for Blood Sampling for Patients with Possibility of VHF Operational Responsibilities 1. To work in conjunction with the Emergency Department (ED) and Infectious Diseases (ID) Consultant in charge. 2. Ensure safety of other patients and staff. 3. Take and label appropriate specimens as listed below. 4. Ensure safe packaging and transport of these specimens to the laboratory or laboratories required. 5. The ED or ID consultant must let the microbiology staff know that bloods are needed to be sent to Porton Down for VHF PCR or not as the case maybe. Protocol: 1. At Monklands Hospital the ED or ID consultant will contact the Microbiology Consultant during normal working hours on pager 241 or extension 2117/8. Out of hours they should contact the On-call Microbiology consultant via switchboard to alert them that samples from a possible VHF patient will be transported to them. Name and CHI number of patient should be provided to the Microbiologist 2. The Consultant Biochemist will liaise with the Consultant Microbiologist and/or the ID Consultant to determine the clinical need of the patient and whether routine laboratory Biochemist sample analysis is required for the immediate management of the patient. 3. Please ensure that the BioPack remains in the ante-room and blood samples can be added to the bubble wrap being held by the buddy. These can then be placed onto the appropriate labelled box. 4. The Ebola Laboratory kit package should contain all the necessary equipment to ensure that sampling happens in an organised and safe manner which will include: a. Selected bottles for ONLY the following samples: i. Haematology: 1. Citrated pale blue top: Minimum 2ml for clotting 2. EDTA purple top: Minimum 2ml for FBC/malaria ii. Biochemistry: 1. Yellow top: 5-10ml for U/E, CRP, LFTs & Glucose iii. Microbiology: 1. Yellow top: 5-10ml for VHF serology 2. EDTA purple top: Minimum 2ml for VHF PCR 3. Blood culture bottles (2) Version No.2.3 December 2014 Page 28 of 35 Management of Viral Haemorrhagic Fevers 5. Check the lids are firmly fixed on all bottles 6. Attach labels to blood sample tubes and blood cultures or handwrite all required details on all bottles before taking blood. 7. Wear PPE as per protocol following risk assessment. 8. Take Blood using Vacutainer only. 9. Wipe the outside of the tubes with a chlorine based wipe, removing any visible contamination, and allow to air dry. 10. Blood tubes or blood culture bottles that are visibly contaminated with blood or are leaking will not be accepted by the laboratory and repeat samples will be required. 11. Place all sharps into a sharps bin and seal it. 12. Don a new (third pair) of gloves before handling the BioPack packaging and packing the disinfected blood samples into it 13. Follow the instructions for the use of the BioPack. 14. Do not use pathology transport bag for the samples. Insert these tubes into the bubble wrap provided in each pack labelled accordingly as biochemistry, haematology and microbiology. 15. Place each of the blood culture bottles into a clear pathology transport bag and seal the transport bags and place these samples into the BioJar 16. Screw the top onto the container. 17. Wipe down the outside of the container with alcohol wipes, Chlorox wipes, or a chlorine based solution 18. Ask the designated person waiting outside the room with the transport box, to open the door. Insert the jar into the box without touching the box. 19. The laboratory request from should be completed appropriately outside of the patient’s direct clinical area and inserted outside the jar but inside the box. 20. At Monklands Hospital, the designated person must take the samples to the Microbiology laboratory on the basement floor. The designated person for the ID unit is a member of the clinical team. The designated person for the ED is a clinical support worker. 21. Only hand samples directly to the named individual expecting the samples. Version No.2.3 December 2014 Page 29 of 35 Management of Viral Haemorrhagic Fevers Version No.2.3 December 2014 Page 30 of 35 Management of Viral Haemorrhagic Fevers Appendix 6 – Categorisation and Management of Contacts Risk Category Description Action & Advice No direct contact with the patient or body Reassure about absence of risk No risk No restrictions or monitoring required (Category 1) Low risk (Category 2) High risk Direct contact with the patient, e.g. routine medical/nursing care, handling of clinical/laboratory specimens, but did not handle body fluids, and wore personal protective equipment appropriately. Unprotected exposure of skin or mucous membranes to potentially infectious blood or body fluids, including on clothing and bedding. (Category 3) This includes: unprotected handling of clinical/laboratory specimens mucosal exposure to splashes needlestick injury kissing and/or sexual contact. Version No.2.3 December 2014 Reassure about low risk Passive monitoring Self-monitor for fever and other disease compatible symptoms for 21 days from last possible exposure Report to the Monitoring Officer if temperature >37.5ºC, with further evaluation as necessary No restrictions required on accommodation and social contact; HCWs must not undertake BBV exposure prone-procedures (EPPs) Inform about risks Active monitoring Record own temperature daily for 21 days following last contact with the patient and report this temperature to the Monitoring Officer by 12 noon each day, with further evaluation as necessary. Inform Monitoring Officer urgently if symptoms develop. Restrictions to be in place for accommodation, social contact and work Page 31 of 35 Management of Viral Haemorrhagic Fevers Appendix 7: WHO (2014) Correct Method of putting on and removing PPE or link to HPS PPE Training Slides Version No.2.3 December 2014 Page 32 of 35 Management of Viral Haemorrhagic Fevers Appendix 8: Health Facilities Scotland Waste Management Guidance for Highly Infectious Waste to Accompany HPS Guidance NHS Lanarkshire 1. The NHS Lanarkshire waste contractor should be notified that highly infectious waste is being produced or may be produced from a suspected case. Notification can be made by the clinician or via the Board’s NHS Waste Manager. Contact Harry Campbell NHS Lanarkshire Head of Technical Services Tel: 01698 377697 Mobile: 07919 396816 2. ‘Soft’ waste should be double bagged in YELLOW clinical waste bags. Bags should then be placed in a suitably sized rigid container for incineration (burn container). The container should then be placed in a rigid 770 Ltr UN wheeled container. 3. Any sharps waste should be placed in a regular sharps container (the smallest size needed to accommodate the amount of waste produced, ensuring the sharps box is not filled more than ¾ full). The container should then be sealed and placed in a suitably sized rigid container for incineration (burn container). The container should then be placed in a rigid 770 Ltr UN wheeled container. 4. The outer packaging of highly infectious waste containers must be clearly labelled, the label must state: • Waste description: ‘highly infectious waste’; • The source or point of generation of the waste: ‘room x / ward x’; and • The date produced. In the absence of pre-printed labels this information should be handwritten on the external container. 5. The Contractor should liaise with the site regarding suitable short-term on-site quarantine storage for highly infectious wastes separate from ALL other wastes. If a quarantine area is not immediately available waste should be stored in the patient’s room in a safe manner e.g. bagged and boxed. Quarantine areas for highly infectious waste should be away from areas used to store other wastes, including other clinical wastes. Where practicable within the quarantine area boxes containing highly infectious waste should be placed directly into a dedicated 770 litre wheeled container to avoid double handling of the waste before uplift. Quarantine areas should be locked to prevent unauthorised access and a record of all waste entering and leaving the area should be maintained. 6. The timing and frequency of collection must be agreed with the waste contractor at a local level. Highly infectious waste should not be permitted to accumulate. 7. The contractor is responsible for providing any additional packaging or labelling required prior to movement off site. 8. The Board will work with the contractor in order to obtain the DfT derogation required to move this waste in line with the Carriage Regulations 1996 (as amended). 9. In the event that this procedure requires to be activated any associated costs will appear in the regular monthly invoice, thus no further authorisation should be required from the Board Waste Management Officer. Version No.2.3 December 2014 Page 33 of 35 Management of Viral Haemorrhagic Fevers Appendix 9 – VHF Contact Tracing Record NHS Lanarkshire - SUSPECTED VHF CASE: CONTACT(S) RECORD (Please complete this form if a suspected case of VHF has been in a common waiting area with other patients/public prior to assessment and/or isolation) Case Name: CHI: Case Status on Risk Assessment (low/high possibility) Address: ED Consultant: Contact No: GP: Hospital: Patient transport details: Name of Contact Tracer: Designation: Date: PH contacted: Y/N Contact No: Please fax form to Public Health on 01698 858283 or send it to healthprotection@lanarkshire.scot.nhs.uk and follow-up with confirmation tel. call on 01698 858232 If you have any queries on completing this form please contact Public Health on 01698 858232 Name Category of Contact CHI (i.e. patient/staff and specify no/low/high risk – refer to Section V, Appendix 6) Home Address Telephone No. Risk Factors / Vulnerable Group1 E.g. children, pregnant women, immunocompromised, those with comorbidities, health care worker Version No.2.3 * For completion by Public Health G.P. Contact Informed Informed 1. 1 G.P. Name And Practice December 2014 Page 34 of 35 Notes/Comments Management of Viral Haemorrhagic Fevers Name Category of Contact CHI (i.e. patient/staff and specify no/low/high risk – refer to Section V, Appendix 6) Home Address Telephone No. Risk Factors / Vulnerable Group1 * For completion by Public Health G.P. Contact Informed Informed 2. 3. 4. 5. 6. Version No.2.3 G.P. Name And Practice December 2014 Page 35 of 35 Notes/Comments
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