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.

Administrative considerations

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.

Equipment

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

diseases.

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

§      Diarrhoea

§      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.