7. NOTIFICATION AND CONTROL OF OUTBREAKS OF VHF
7.1 Transfer of VHF patients
7.1.1 Arranging transfer of VHF patients
Reasons for and against transfer of VHF patients
Patients are often transferred through one or more hospitals before VHF is suspected. However, once VHF is suspected or confirmed, the following points must be taken into consideration:
Indications for transfer of VHF patients
The most important reason for transferring a patient is the need for better medical care. Another valid reason is to achieve greater safety in isolation and nursing of patients. Thus, there are stronger grounds for moving moderate or high risk patients to better facilities, but low risk patients are easier to move safely (see section 5 for discussion of risk categories). The existence of a conveniently-located referral centre which has been specifically designated and equipped to receive VHF patients, is an obvious incentive to transfer patients.
Contraindications to the transfer of VHF patients
Patients should not be moved when their condition does not allow this to be achieved safely: the process may unduly threaten the life of the patient, or involve too great a risk of spreading infection. It is inadvisable to move patients when there appears to be a continuing outbreak of infection, as in common source outbreaks in abattoirs or on farms, or when there has been definite exposure of contacts (as in nosocomial needle sticks), or when secondary cases have already become manifest. The inference is that further cases may arise and that transfer of patients merely results in creating two or more potential centres of infection where contacts have to be placed under observation. Under certain circumstances, therefore, it is better to second trained staff and the required equipment to the primary hospital, than it is to move patients.
Reaching a decision on transfer of VHF patients
Decisions are reached with greatest facility where a framework for consultation has been organized as a matter of preparedness. Thus, a pre-arranged panel within the primary hospital should perform the initial clinical evaluation and decide whether there are indications for seeking transfer of patients. The panel should include clinicians, infection control and management representatives. Advice can be sought from the medical officer on duty at the National Institute for Communicable Diseases (NICD) (NICD Hotline 082 883 9920).
Once it has been decided to seek transfer of a patient, it should only be necessary to contact one person per telephone at the referral hospital. This person should be authorized to take decisions on accepting transfer of VHF patients, or be able to obtain decisions rapidly. Experience has shown that decisions can be reached with suitable expediency (see requirements for a VHF referral centre on the following pages). Arrangements for transporting the patient should be made at the same time (see 7.1.2 and 7.1.3 below).
If the primary hospital does not have information available on provincial policy with regard to referral of VHF patients, or contact details for a referral hospital, information can be sought from the provincial Coordinator of Communicable Disease Control (see section 7.2), who must in any event be informed of transfers of VHF patients.
7.1.2 Non-ambulance transport of low risk VHF patients
Before VHF is diagnosed, patients are usually transported to doctors’ rooms or hospital without special precautions. Once VHF is suspected, patients should not be transported without specific precautions to prevent spread of infection. However, there is generally room for judicious improvisation in transporting VHF patients in the early stages of disease. For instance, when febrile illness first occurs in a known VHF contact, there appears to be no valid objection to the patient being taken to hospital in the vehicle of a relative with whom the patient has already had close contact. The safety of those in attendance should nevertheless remain a prime consideration and patients who are severely ill, or who are vomiting or manifesting haemorrhagic signs, should only be transported by an ambulance crew using appropriate personal protective equipment (see 7.1.3 below).
7.1.3 Transport of VHF patients by ambulance
There appear to be no strong reasons for the transportation of suspected or confirmed VHF patients by air within South Africa, and this has not occurred during the past decade.
As recommended for hospitals, ambulance and emergency medical services are advised to ensure that staff is trained in the recognition of VHFs, assessment of the condition of patients, and in essential isolation precautions for safe transportation of patients (see 6.3). This applies particularly, but not exclusively, to ambulance crews, which provide a service for designated VHF referral hospitals. Ambulance crews tasked with the transport of VHF patients at referral centres should ideally be composed of volunteer personnel, and be contactable through a designated individual to whom all requests for transport of VHF patients should be channelled.
Ambulance and emergency medical services should keep stocks of personal protective equipment (PPE), most conveniently in the form of formidable epidemic disease (FED) packs, each containing:
§ Disposable gown 1
§ Disposable balaclava type cap 1
§ Dust goggles 1 (alternatively a clear acrylic visor or disposable visor)
§ Disposable plastic aprons 2
§ Theatre masks, moulded 2
§ Surgical gloves 2 pairs
§ Overshoes 2 pairs
In addition, there should be decontamination (DECON) packs each containing:
§ Plastic autoclave bags (preferably red) 10
§ Sharps disposal container
§ Biocide D Extra or equivalent disinfectant, 50 sachets
§ Biohazard labels
§ Felt tip marker pen
§ Masking tape 1 roll
§ Plastic cable ties for sealing bags 12 (obtainable from electrical/hardware stores)
§ Paper towels 4 rolls
§ 10 litre plastic bucket (it is a good idea to mark 1 litre graduations on the bucket)
Ambulances despatched to transport suspected or confirmed VHF patients should carry 10 FED and 2 DECON packs. Although the ambulance should be stripped of non-essential equipment, it should carry a suction unit, a complete oxygen supply unit and the standardrange of equipment for management of patients. Items could be sealed into plastic bags with adhesive tape and opened only if required.
Battery-operated positive-pressure ventilated respirators (‘pappers’) (e.g. Racal ‘Dust Master’, Delta Health & Safety, Kempton Park) with disposable hoods could replace the balaclava, face mask, goggles or visor in high risk situations. Two pappers are required per ambulance crew, and they must be maintained in working order with batteries charged at the base from which the ambulance operates. Pappers can generally be used for up to 8 hours with fully charged batteries. The disposable hoods are relatively expensive.
Operational procedures for the transportation of VHF patients by ambulance
A minimum ambulance crew of 3 members is required for the transportation of a VHF patient. The clinician requesting transport should advise the ambulance team of the condition of the VHF patient and of the appropriate protective measures to be taken, eg:
§ Conscious patient, no vomiting, no active visible haemorrhage, in full control of urinary bladder and bowel function - ambulance crew to use protective clothing as contained in FED packs; and
§ Patient with disturbed level of consciousness, vomiting, possible haemorrhages or pulmonary involvement, not in control of urinary bladder or bowel functions - the use of battery-operated positive-pressure ventilated respirators (‘pappers’) with hoods in place of the balaclava cap, masks and goggles or visors is advisable, particularly if there is to be nebulization, suctioning, intubation and manual ventilation of the patient.
The donning and removal of PPE and the use of pappers for safe transport of VHF patients should follow the routines described for isolation precautions for VHF patients in hospitals, with disposal of soiled items into double autoclave bags, sealed with cable ties or adhesive tape and labelled with biohazard stickers (see sections 6.3; 6.4). Re-usable items should be bagged separately from disposable items. Sharp instruments, particularly needles, should be used with great care and disposed of into appropriate sharps disposal containers.
On arrival at the location of the patient, the 3 crew members should all don protective clothing, but the driver should avoid contact with the patient and act as a liaison between the other 2 crew members and local hospital staff to ensure safe transfer of the patient into the ambulance.
Five of the FED packs should be carried in the driver's compartment and these could be made available to the personnel at the referring hospital if necessary for use in transferring the patient and in decontaminating afterwards (information on hospital decontamination procedures can be found in section 6.4 of this document).
Before transferring the patient, the crew should re-assess his/her condition and if necessary consult the clinical team at the referral hospital per telephone if there has been marked deterioration. Patients must be brought by wheeled bed or hospital trolley to the ward entrance and then transferred to the ambulance stretcher, to minimize further contamination of the hospital, and passages should be kept clear during transit of the patient. The receiving hospital should be given an estimated time of arrival by the ambulance crew, and the patient should be taken by shortest route to the appropriate ward through passages which are kept clear during the transit.
Decontamination of the ambulance and disposal of hazardous items
Crew members decontaminating ambulances should don PPE as contained in FED packs. During or after transport of a VHF patient, vomitus, blood and other spillages should be flooded with disinfectant at a concentration of 5000 ppm available chlorine (20x30g sachets of Biocide D Extra/10L water - see section 6.4), and covered with paper towels for at least 30 minutes before being wiped up. Overt spillages should never be sprayed with disinfectant.
Containers with secretions, excretions and other wastes such as vomitus and blood, should be flooded with copious chlorine disinfectant at a concentration of 5000 ppm (20x30g sachets of Biocide D Extra/10L water - see section 6.4) for at least 30 minutes.
All items leaving the ambulance should be enclosed and sealed in adequate layers of autoclave bags to prevent leakage. The outer surfaces of the bags should be wiped with chlorine disinfectant at a concentration of 500 ppm (2x30g sachets of Biocide D Extra/10L water - see section 6.4) and labelled to indicate that the bags contain biohazardous material. Disposable items should be sent for incineration under supervision and re-usable items sent for autoclaving.
The ambulance interior should be swabbed, including fittings, with chlorine disinfectant at a concentration of 500 ppm (2x30g sachets of Biocide D Extra/10L water - see section 6.4). It is convenient to dispense 500 ppm chlorine disinfectant from rigid-walled plastic spray bottles for cleaning surfaces which are not visibly contaminated.
Crew members who decontaminate ambulances should remove their PPE as described for isolation precautions during nursing of VHF patients in hospitals, with disposal of soiled items into double autoclave bags, sealed with cable ties or adhesive tape and labelled with biohazard stickers (see sections 6,3; 6.4).
7.1.4 Importation of VHF patients and transportation by air
South Africa accepted transfer of an American citizen with suspected Ebola fever from Zaire (DRC) in 1976 (laboratory tests proved to be negative), but since then it appears that no country has granted permission for the intentional importation of suspected or known cases of VHF, although technically countries could not exclude their own citizens. However, there have been many unwitting importations of VHF patients worldwide, sometimes resulting in the occurrence of fatal nosocomial infections, also in South Africa.
As with other countries, South African regulations pertaining to the importation of suspected or known cases of VHF are intended to give effect to the International Health Regulations of 2005 (IHR 2005), which aim to control national and international spread of contagious
The importation of patients into South Africa by air occurs in two ways:
Intentional importation of patients – patients who are referred for medical attention are often assisted by evacuation companies which operate their own air ambulance services, but which may utilize scheduled commercial airline flights for ambulant patients with non- contagious conditions.
§ It is the responsibility of the aeromedical assistance company to ensure that visas are obtained for patients if necessary from the Department of Home Affairs.
§ If the patient’s condition is considered to be non-contagious (eg traumatic, surgical, obstetric or neoplastic) the pilot of the medical evacuation flight need only submit a general declaration (GENDEC) by facsimile to the Port Health Officer (PHO) at the port of intended entry, most often O.R.Tambo or Lanseria airports.
§ If a contagious disease (or suspected VHF) is involved, the aeromedical assistance company (pilot) must obtain prior clearance for importation of the patient through submission of a duly completed request form AC1 by facsimile to the PHO at the intended port of entry. The PHO must obtain expeditious clearance from the provincial Directorate of Health and Hospital Services (specifically the office of the Coordinator of Communicable Disease Control), which may in turn consult, or at least must notify, the national Ministry of Health. In practice, the referring clinicians in the country of origin of the patient, the aero-medical assistance company, as well as health authorities and the referral hospital within South Africa, often seek advice from the medical officer on duty at the NICD (NICD Hotline 082 883 9920) in instances where VHF may be involved.
§ The PHO informs the pilot or person who made the request of the decision to permit or decline permission for importation of the patient by facsimile of form PH1, with a reference number. In general, requests for importation of suspected or known cases of VHF will be declined unless there are exceptional circumstances, eg a South African citizen is involved.
Aeromedical assistance companies, and hospitals which accept patients from abroad, are well advised to comply strictly with the legal requirements for their own safety and the safety of others, as well as to avoid liability to prosecution or litigation. Aeromedical assistance companies have the same obligations as hospitals and ambulance services to ensure that staff is trained in the recognition of VHFs, assessment of the condition of patients, and in essential isolation precautions for safe transportation of patients (see 6.3).
Air ambulances should have available the same safety equipment as recommended for road ambulances (e.g. PPE FED packs and DECON packs, plus pappers) (section 7.1.3 above), and apply the same operational principles in transporting patients as described for ambulances. The use of pappers is particularly advisable if there is to be nebulization, suctioning, intubation and manual ventilation of potential VHF patients within the confined space of an air ambulance.
Although most instances of intentional importation of potential cases of VHF have involved Gauteng airports commonly utilized for medical evacuation of patients from tropical Africa, the increasing tourist trade and the institution of direct flights to remote destinations implies that vigilance should be maintained at all South African airports. Management of a suspected VHF patient on arrival at the port of entry is discussed below (see procedure below on the arrival of a flight with a suspected or known VHF patient).
Unintentional importation of VHF patients - patients who are being medically evacuated to South Africa ostensibly for non-contagious diseases may develop signs and symptoms suggestive of VHF or other formidable infectious disease (eg avian influenza) in transit. It also occurs that patients suffering from suspected VHF (or other notifiable disease) travel to South Africa on scheduled flights on their own initiative, sometimes specifically to seek medical attention here, without declaring their illness to the airline. Hence, aircrew members on commercial and medical evacuation flights should be trained to recognize the following signs and symptoms suggestive of VHF (or other formidable infectious diseases) in passengers:
§ Fever (≥38.5C)
§ Severe headache
§ Abnormal sweating
§ Rapid breathing
§ Excessive coughing
§ Severe vomiting
§ Bleeding - eg nosebleed or vomiting blood
The crew should attempt to isolate the patient and to avoid contact between the patient (or secretions and excretions) and other passengers as best as can be managed under the circumstances.
The pilot should notify the control tower at the airport of intended arrival of the existence of the patient on board, and the tower should arrange for the flight to be met by a PHO. The crew should complete form AC2 ‘for notification of symptoms of a patient/sick passenger transported per aircraft to South Africa’, and this should be handed to the PHO on arrival.
Screening procedures to detect febrile patients are increasingly being instituted within international airports following the occurrence of the SARS and avian influenza pandemics of recent years, and this represents a further method by which potential imported cases of VHF may be detected.
Procedure on the arrival of a flight with a suspected or known VHF patient
The flight must be met by port health officials, including a medical officer if necessary, to assess the patient and the likelihood that VHF is involved, and the doors kept closed (no disembarkation allowed) until formalities have been completed. A duly completed form AC2 should be handed to the PHO if relevant.
Prior arrangements for patients arriving on medical evacuation flights to be transported by ambulance and admitted to referral hospitals, should be permitted to proceed with due warning to the aircraft crew, ambulance crew and the hospital concerned that VHF may be involved, so that appropriate safety procedures can be instituted. If a suspected VHF patient arrives on a scheduled flight without prior arrangements for admission to a hospital in South Africa, the PHO should arrange for transportation and admission of the patient to a hospital designated for medical management of VHF patients (there should be standing arrangements for PHOs to refer patients to designated hospitals through liaising with authorized contact persons at the hospital – see 7.1.1: reaching a decision on transfer of VHF patients).
There should be a designated area within the airport for temporary isolation of patients awaiting transport to a designated hospital. The pilot should permit the public address system to be used to inform the crew and passengers calmly and factually that there is an ill person on board and to explain the precautionary measures which are being taken, before disembarkation is allowed.
All passengers and crew members should be given an information sheet plus a Health Alert
Notice which is to be handed to a medical clinician should the person develop febrile illness within the ensuing 3 weeks. Contact details for those crew members and passengers on the aircraft deemed to have been exposed to possible infection should be recorded by the PHO and given to the office of the provincial Coordinator of Communicable Disease Control (along with a complete passenger list) so that the persons at risk can be placed under observation if deemed necessary (see section 7). In deciding which persons may have had contact with the patient or secretions and excretions in such a manner as to have been exposed to possible infection (see definitions in section 7) it is advisable to include passengers seated in same row (aisle to aisle) as the patient, plus those seated in the two rows behind and the two rows in front of the patient.
People deemed to have been exposed to possible infection should be especially well briefed on the precautionary measures and their responsibilities, if necessary in a room in the airport. The PHO should assess the need for disinfection of affected parts of the aircraft cabin and arrange for this to be conducted as described for ambulances (see under 7.1.3 above).
The use of transport isolators for conveyance of passengers by air
Transport isolators are not available except through the military services.
7.1.4 Importation of VHF patients into South Africa by land and sea
The importation of VHF patients into South Africa by land seems less likely than by air, but did occur in 1975 when two people who had been hitch-hiking in Zimbabwe developed Marburg disease shortly after entering South Africa, with the subsequent occurrence of nosocomial infection in a health care worker in Johannesburg.
There appears to be a real but small risk of importing cases of VHF into South Africa by sea, with the rat-borne Seoul hantavirus being the most likely candidate. Moreover, there are well-documented instances where crew members and passengers of ships sailing from tropical destinations were found to be suffering from mosquito-borne infections such as yellow fever and dengue fever. It is believed that a ship sailing down the east coast of Africa ignited a large epidemic of dengue fever in Durban in 1926 (before the causative agent of the disease was known). Consequently, PHOs at sea ports of entry should maintain the same vigilance and apply the same principles of VHF control as prescribed for major airports, including awareness of the possible importation of disease through disembarkation of passengers and crew members at ports, as well as through medical evacuation of sick persons from ships at sea by boat or helicopter.
7.2 Notification of cases of VHF
In terms of regulations promulgated under Health Act 61 of 2003, the VHFs are category A notifiable diseases which should be reported to the Department of Health by telephone within 24 hours of being diagnosed, with written notification on form GW17/5 (Figure 7.1) to follow within 5 days. However, it is important for implementation of control measures that additional information should be supplied, including details of clinical presentation, and this can be achieved conveniently by use of a checklist such as shown in Figure 7.2.
Notification should be made by the health care professional tending the patient as soon as possible after it has been decided to proceed on the assumption that VHF may be involved, or after a diagnosis of VHF has been confirmed, depending on which occurs first.
Reports should be made to the National Department of Health, Directorate: Communicable Disease Control (CDC), Pretoria, plus the relevant Provincial Coordinator of CDC listed in Table 7.1 below. The National Department of Health will notify World Health Organisation (WHO).
7.3 Public health response to VHF outbreaks
7.3.1 Immediate responsibilities of Provincial CDCs during outbreaks of VHF:
● Ensure that correct laboratory and autopsy investigations are undertaken to establish an aetiological diagnosis (see section 4.3).
● Investigate the source of the outbreak.
● Trace and place under observation all VHF contacts in the community at large, beginning with the family and cohorts of VHF patients (see below for definitions of contact and observation).
● Ascertain whether the hospital authorities are treating VHF patients under appropriate conditions of isolation precautions, and whether the hospital infection control staff have traced and placed all health care workers who have had contact with the patient/s or fomites under observation.
● Participate as necessary in the decision-making process as to whether VHF patients should be treated in the primary hospital (the hospital where the diagnosis of VHF was first suspected) or should be transferred to a referral hospital, and help facilitate approved transfers (see section 7.1).
● Supervise disposal of corpses of VHF patients (see section 6.3.3).
● Convene a VHF Outbreak Control Committee if necessitated by the circumstances of the outbreak as indicated below.
● Collate information and disseminate it to those who need to be kept informed, including news media as discussed below.
● Take any further action as may be appropriate and necessary to attain containment and control of the VHF outbreak, and ensure that no fundamental steps or procedures are overlooked.
Indications for convening a VHF Outbreak Control Committee
Hospital staff and provincial CDC personnel can manage small outbreaks of indigenous VHF. For example, where only one person develops Congo fever after being bitten by a tick it may only be necessary for provincial CDC officials to warn family members and cohorts of the patient to take precautions against exposure to ticks and blood of livestock, and to place persons potentially exposed to infection under observation for 2 weeks. The virus is widely distributed in South Africa and it makes no sense to quarantine properties.
In contrast, the investigation and control of large outbreaks, or introduced exotic infections (diseases not indigenous to South Africa), may require recruitment and coordination of large teams. Thus, the diagnosis of Ebola fever in a nurse in Johannesburg in 1996 necessitated a search for the source patient, and the identification and screening of about 1,500 potential contacts of the patients at two hospitals and in the community at large, resulting in 350 persons being placed under 3 weeks observation and subjected to intensive investigation if they became sick. It was necessary to co-opt administrators of the affected hospitals plus a quarantine facility, infectious disease consultants, epidemiologists, military medical personnel, local health authorities, plus members of ambulance, laboratory, mortuary and blood transfusion services, with operations coordinated by a VHF Outbreak Control Committee which held daily meetings to monitor the situation. Control of the 2008 outbreak of nosocomial infection with the novel Lujo virus in Johannesburg required similar coordination.
A multi-disciplinary approach is crucial in public health when responding to large VHF outbreaks. This includes doctors, nurses, epidemiologists, laboratory technicians, environmental health specialists, administrations etc. The response should be organised by forming different sub-committees with roles and responsibilities as shown in Table 7.2 below.
7.3.2 Tracing of contacts
The purpose of tracing VHF contacts and placing them under observation is to control spread of infection and thus to terminate an outbreak. The office of the relevant provincial Coordinator of CDC is ultimately responsible for tracing and observation of contacts. In practice, infection control officials within hospitals where VHF patients are treated assume responsibility for placing health care workers who have had contact with the patient/s or fomites under observation, and this is done irrespective of whether or not contact took place before or after isolation precautions were instituted.
Concurrently, provincial CDC teams operate within the community at large to trace the movements of the VHF patient/s for up to 3 weeks prior to onset of illness in order to establish the source of infection, and to prepare a list of all contacts who are at risk of developing the disease and need to be placed under observation (a period of 3 weeks prior to onset of illness applies for Marburg, Ebola, Lassa and Lujo fevers, but 2 weeks is appropriate for Congo fever and other arbovirus diseases, see section 3).
An outbreak of VHF is the occurrence of one or more cases of VHF.
An index patient in an outbreak of VHF is the first patient in whom the disease is recognized, and is not necessarily the primary case, i.e. is not necessarily the first person to have become infected in the outbreak. Recognition of the disease in the index patient results in the discovery of the outbreak.
A multiple case outbreak of VHF can arise when there is secondary human-to-human spread of infection from a primary case.
Common-source outbreaks occur when more than one primary case of infection arises from exposure to a natural source of infection, e.g. infected animal tissues.
A source patient is a patient from whom transmission has occurred to produce secondary infection/s.
A contact is a person who has been exposed to an infected person, animal or contaminated environment in such a manner as to have had the opportunity to acquire infection.
A case contact is a person who has been exposed to an infected person or his/her secretions, excretions, blood or other tissues in such a way as to be at risk of acquiring infection.
A source contact is a person who has been exposed to the same external (non-human)
source/s of infection as an infected person.
Low risk contacts have had slight or indirect contact with a VHF patient or other source of infection on a single or few occasions.
Moderate risk contacts have had close and prolonged contact with a VHF patient or other source of infection. This category includes intimate friends of a VHF patient, relatives and health care workers.
High-risk contacts have had what is judged to be definite exposure to VHF infection, e.g. needle-stick with blood from a confirmed case of VHF or similar exposure to animal tissues in a common-source outbreak.
Exposure to infection which constitutes contact for purposes of VHF control includes association with an infected person at any time from onset of fever until 3 weeks later in any of the following ways:
§ Sharing the same residence.
§ Face-to-face contact (≤1 metre).
§ Skin or mucous membrane contact or penetrating injury with the patient's secretions, excretions, blood or other tissues. This includes exposure to animal tissues or insect bites in situations where such exposure is considered to be the source of infection.
In tracing and assessing persons potentially exposed to infection, interviews should be based on questionnaires prepared specifically for the circumstances of the outbreak under investigation (see Figure 7.3 for an example). Persons assessed as having been exposed to infection as defined above, are included on a list of contacts to be placed under observation.
7.3.3 Observation of contacts
Observation of contacts of VHF consists of recording temperatures twice daily for 3 weeks (21 days) from the last date of contact with a VHF patient or fomite, and monitoring for signs and symptoms of illness. A 21 day observation period is appropriate for Marburg, Ebola, Lassa and Lujo fevers, but 14 days is adequate for Congo fever, which has a shorter incubation period.
Rift Valley fever also has a short incubation period, but the virus seldom causes serious or haemorrhagic disease and person-to-person spread has not been recorded, so active observation is not essential.
Persons with ongoing exposure to infection, such as health care workers engaged in nursing of VHF patients, remain under observation while exposure continues to occur, and are kept under observation for the requisite 14 or 21 day period after the last date of potential exposure to infection.
Active observation involves contacts being seen twice daily by a medical official charged with this responsibility. Passive observation entails the contact reporting (e.g. by telephone) on their own status to the observation officer. Passive observation is sometimes applied to contacts deemed to be reliable, e.g. health care workers, but this must not be permitted when VHF is involved.
It is important to note that the term observation is used in preference to surveillance since the terms active surveillance and passive surveillance are used in a different sense to denote monitoring of a population for the occurrence of a disease either actively through sampling a sub-population or passively through simply testing samples submitted voluntarily to the laboratory.
Contacts should be seen at pre-arranged venues and times, which could include their place of employment, e.g. a hospital, or their place of residence, e.g. a farm, and specific arrangements must be made for monitoring of contacts at weekends or other times of absence from duty. All contacts must be seen twice daily at fixed times and any unexplained absences from work or home must be investigated.
No medical official should be responsible for monitoring more contacts than can be conveniently managed; in large outbreaks 10 contacts per monitor has been found to be convenient. Temperatures and illnesses reported by contacts should be recorded on a standard list (see an example presented as Figure 7.3), but care should be taken not to ask leading questions: let the contacts describe how they feel.
Low to moderate risk contacts of VHF (see definitions in 7.3.2 above), including health care workers, may be kept under active observation in their normal environment and employment, but should not leave the town/district until the observation period has ended. This provision is enforceable in law. High-risk contacts of VHF (see definition in 7.3.2 above) must be kept under active observation or placed under quarantine in a suitable facility for the duration of the quarantine period.
It is not universally agreed that there is a need to confine high risk contacts to a quarantine facility, provided they are kept under strict active observation. At most, confinement to a quarantine facility should be applied selectively to those considered to be in imminent danger of developing infection, e.g. medical staff who have had a needle-stick injury with blood known to be infected, or those who have developed non-specific illness, e.g. fever and headache.
Quarantine facilities need not necessarily be in the same complex as VHF isolation units. Old infectious disease hospitals in isolated localities are ideal, and since confinement of essentially healthy people may be involved, it is advantageous to have access to an outdoor area.
Any contact who develops fever (temperature of 38°C or over) or signs and symptoms suggestive of VHF, must be placed in isolation and treated as a suspected case.
Although monitoring of individual patients ceases on completion of the requisite 14 or 21 day period after the last date of potential exposure to infection, outbreaks are only declared to be over after twice the duration of this period has passed, 28 or 42 days since the last known potential exposure of any person to infection. Hospital infection control and provincial CDC personnel must continue to monitor the situation during this precautionary period.
Counselling of contacts and health care workers should be considered to counter stress during outbreaks.
7.4 Communication with the media
News media can be disruptive during outbreaks of VHF through disseminating incorrect and alarmist information, and through making undue demands on the time of officials who are heavily engaged in controlling the outbreak. However, with proper planning and liaison, the media can be utilized to dispel misconceptions and to disseminate useful information. This is best achieved by conducting communications with the media on an organized basis, and issuing factual, non-sensational statements through specially appointed spokespersons who confine themselves to their areas of competence. For example:
§ Spokespersons for the national and provincial Departments of Health can report on control measures, VHF policy and the status of an outbreak.
§ Members of NICD staff can provide background information on VHFs, including
distribution and occurrence of the diseases, sources of infection, means of spread and mortality. It is useful to have succinct fact sheets on the diseases available for distribution.
§ Senior administrators and clinicians in hospitals treating VHF patients can issue suitably guarded statements on the clinical status of patients, bearing in mind the
rights of patients and relatives to preserve their privacy and anonymity.
Information must first be made known to those who have need of it, e.g. it is unacceptable for clinicians or relatives of patients to hear of laboratory findings on the radio, or for officials of the Department of Health to learn of the existence of an outbreak of VHF in the press. Although it is useful to issue approved press statements at set times, it is advisable to have well-informed spokespersons readily available to the media. Refusing to communicate or withholding information does not remove misconceptions. However, officials should not volunteer sensitive information to outsiders or to the media.
7.5 Long-term responsibilities of Provincial CDCs include:
● Drafting contingency plans for managing single or multiple case outbreaks of VHF in the province.
● Formulating policy as to whether cases of VHF should to be referred to a specifically designated hospital, or whether they should be managed in the hospital where the
diagnosis is first suspected. In practice, decisions will vary with individual circumstances.
● Acting in conjunction with the provincial Department of Health and Hospital Services to identify and secure the use of facilities and resources needed for managing outbreaks
and delegating responsibilities, including the designation of specific hospitals as VHF
referral centres (see section immediately below).
● Assisting health care facilities to institute planning and training of health care workers in the recognition, transport, isolation and nursing of patients.
Requirements for a VHF referral centre include:
● Tertiary care hospital which has been specifically designated for referral of VHF patients.
It is usually possible to adapt space within a hospital to serve as an isolation unit for nursing of VHF patients with little or no structural alteration (see section 6.3.1).
● Laboratory unit capable of performing essential clinical pathology tests for monitoring the treatment of VHF patients. It is best to use an existing laboratory, preferably but not
necessarily within the same complex as the patient isolation unit (see section 6.2).
● Quarantine facility for high-risk contacts of VHF patients, such as health care workers who develop non-specific illness after known exposure to infection. Such persons are moved into the isolation unit if a diagnosis of VHF is confirmed. A quarantine facility is seldom required, and it need not be in the same complex as the isolation unit.
● Mortuary with facility for refrigerated storage of corpses until a diagnosis has been confirmed. This need not be within the same complex as the isolation unit and does not require special facilities provided that the corpse is properly disinfected and shrouded.
● Clinicians, nurses, infection control and laboratory personnel trained for evaluation, management, nursing and laboratory monitoring of VHF patients with due isolation precautions.
● A senior person, logically a clinician (plus an alternate), authorized to take decisions on accepting transfer of VHF patients, with appropriate consultation if necessary.
● An ambulance service with paramedical teams equipped and trained for safe transport of VHF patients.
● Personal protective and safety equipment required for transport and nursing of VHF patients.