December 1998

This manual was prepared by:
Centers for Disease Control and Prevention: National Center for Infectious Diseases, Division of Viral and Rickettsial Diseases, Special Pathogens Branch, WHO Collaborating Centre for Viral Haemorrhagic Fevers
and
World Health Organization: Division of Emerging and Other Communicable Diseases - Surveillance and Control

The material in this manual is in the public domain. It may be used and reprinted without permission. The source should be acknowledged. Suggested citation: Centers for Disease Control and Prevention and World Health Organization. Infection Control for Viral Haemorrhagic Fevers in the African Health Care Setting Atlanta, Centers for Disease Control and Prevention, 1998: 1-198.

Introduction

African countries (shaded areas) where viral haemorrhagic fevers have been documented in the past

Viral Haemorrhagic Fevers: An Overview

In Africa, viral haemorrhagic fevers (VHFs) include Lassa fever, Rift Valley fever, Marburg and Ebola haemorrhagic fevers, Crimean-Congo haemorrhagic fever (CCHF) and yellow fever. Humans initially contract an infection with a haemorrhagic fever virus through exposure to rodents or insects (for Ebola and Marburg VHFs, the natural reservoir is unknown). Person-to-person transmission of Lassa, Ebola, Marburg and CCHF viruses can occur through direct contact with VHF-infected material.

Typically, during the course of a VHF, the blood vessels and many organ systems are damaged. VHFs are often accompanied by bleeding, reflecting the widespread presence of the virus throughout the patient's body. As a result, the blood, urine, vomitus, pus, stool, semen and saliva from the VHF patient are infectious. This is why VHFs pose a serious risk to caregivers in the health care setting and in the community.

The transmission risk of VHFs in the health care and laboratory setting is well documented. During the 1995 Ebola haemorrhagic fever outbreak in Kikwit (former Zaire, and now the Democratic Republic of the Congo), one fourth of the cases were in health care workers with a history of recent patient care.¹ After barrier nursing practices (such as wearing protective clothing) were implemented,the risk of transmission was reduced. No new cases were reported among health care workers who used these practices. (Fig.1)

Khan AS et al. The Reemergence of Ebola Hemorrhagic Fever, Journal of Infectious Diseases, 1998.

How VHF Is Transmitted in the Health Care Setting

The virus enters the health facility in the body fluids of a VHF patient

All health care staff, laboratory staff, cleaning staff, other patients and visitors to the health facility are at risk for exposure to VHF.

The virus is transmitted during direct, unprotected contact with a VHF patient OR with a deceased VHF patient.

The virus is also transmitted during unprotected contact with VHF infectious body fluids OR contaminated medical equipment and supplies OR as a result of an accidental needlestick or accidental exposure to infectious body fluids.

The exposed person carries the virus back to the community. Transmission continues if there is direct person-to-person contact OR any unprotected contact with infectious body fluids.

What Is in This Manual?

This manual describes a system for using VHF Isolation Precautions to reduce the risk of transmission of VHF in the health care setting. The VHF Isolation Precautions described in the manual make use of common low-cost supplies, such as household bleach, water, cotton cloth, and plastic sheeting.

Although the information and recommendations are intended for health facilities in rural areas in the developing world, they are appropriate for any health facility with limited resources.

Who the Manual Is For?

The manual is intended primarily for health officers who implement infection control in the health care setting, and for:

• Health facility administrators
• Hospital outbreak coordinators
• Chief medical officers
• Chief nursing officers
• Medical and nursing staff
• Medical and nursing educators
• Public health officers and programme administrators.
  

Objectives

The information in this manual will help health facility staff to:

1. Understand what VHF Isolation Precautions are and how to use them to prevent secondary transmission of VHF in the health facility.
   
   
2. Know when to begin using VHF Isolation Precautions in the health care setting.
   
   
3. Apply VHF Isolation Precautions in a large-scale outbreak. (When a VHF occurs, initially as many as 10 cases may appear at the same time in the health facility.)
   
   
4. Make advance preparations for implementing VHF Isolation Precautions.
   
   
5. Identify practical, low-cost solutions when recommended supplies for VHF Isolation Precautions are not available or are in limited supply.
   
   
6. Stimulate creative thinking about implementing VHF Isolation Precautions in an emergency situation.
   
   
7. Know how to mobilize community resources and conduct community education.
   

How to Use the Manual

This manual can be used as a rapid reference when one or two cases of a VHF appear in a health facility and no previous preparations for VHF Isolation Precautions have been done. Administrators or hospital outbreak coordinators can use the information and instructions to set up an isolation area quickly and make adaptations from local materials so that an effective system of infection control can be implemented as soon as possible.

The manual can also be used for planning and carrying out in-service training aimed at strengthening VHF Isolation Precautions. It can be accompanied by workshop activities, in which participants discuss and practice the recommendations
made in this manual.

The manual should be used to help health facilities make advance preparations for responding with appropriate precautions when a VHF case is suspected.

This manual consists of nine sections:

The Annexes provide additional details about specific topics described in the manual.

Glossary for Use with This Manual

Changing room	Area next to isolation ward where health workers dress in protective clothing, disinfect hands and gloves, and dispose of soiled and contaminated protective clothing.
Cleaning	Removal of any soiling or other material on equipment or surfaces before disinfection or sterilization.
Contamination	Presence of infectious agent in blood and other body fluids, on body surfaces and medical equipment, clothing and supplies. Contact with contaminated body fluids or items is a risk for disease transmission.
Disinfection	Elimination of most microorganisms from a surface, making it safe for reuse. "Sterilization" means eliminating all microorganisms.
Health care worker	Any person trained to provide patient care (medical, nursing, paramedical, emergency room nurses, community health workers).
Health facility	Any hospital, health centre or clinic with inpatient facilities. Also any facility providing emergency or first-service care.
Health facility staff	All patient care, laboratory, cleaning, disposal, reception, and administrative staff who are likely to have contact with suspected VHF cases, VHF infectious body fluids, and infectious waste.
Isolation area/ward	The area in the health facility used for housing suspected VHF patients. It includes the patient's room or area, isolated latrine or toilet, family entrance, and changing room.
Protective clothing	Masks, gloves, gowns, eyeglasses, caps, aprons, and boots. Provides protection against splashes or spills of infectious material when examining suspected VHF cases or handling infectious waste and laundry.
Sharps container	Puncture-resistant container for collecting used needles and syringes. Standard Precautions Practices for limiting or preventing disease transmission in the health care setting.
Sterilization	Elimination of all microorganisms (viral, bacteria, and fungal) through heat, using an autoclave or steam sterilizer, or other appropriate methods.
VHF Coordinator	Designated health officer who coordinates infection control and outbreak response, and provides liaison with the community and other agencies involved in outbreak control.
VHF Isolation Precautions	Barrier nursing and other infection control practices for preventing contact between VHF infectious body fluids and non-infected persons.

Acknowledgments

The contributions of the following organizations to the preparation and review of this document are gratefully acknowledged:

• Centers for Disease Control and Prevention
  -- Hospital Infections Program
  -- Office of Health and Safety
• World Health Organization
  -- WHO Regional Office for Africa
  -- WHO Country Programmes in Kenya and Gabon
• Centre International de Recherché Médicales de Franceville, Gabon
• Communicable Disease Surveillance Centre, United Kingdom
• Dr. Kalongi and the staff of Clinique Bondeko, République Démocratique du Congo
• École de Médecine, Université de Kinshasa, République Démocratique du Congo
• Épicentre, France
• Fogarty International, USA
• Hôpital Général de Kikwit, République Démocratique du Congo
• Institut de Médecine Tropicale, Belgium
• Institut de Recherche Biologique Appliquée de Guinée
• Institut Pasteur à Paris, France
• Institute of Virology, Germany
• Johns Hopkins School of Public Health, USA
• Lassa Fever Research Projects, Guinea, Sierra Leone
• Medical Emergency Relief International, United Kingdom
  
• Médecins Sans Frontières, Belgium
• National Institute of Virology, South Africa
• Participants attending the CDC WHO VHF Isolation Precautions workshops held
  at Mumias, Kenya, and Booué, Gabon
• Swedish Institute for Infectious Diseases, Sweden
  
• Tulane University, USA
• United States Army Medical Research Institute of Infectious Diseases, USA
• Virus Research Centre, Kenya Medical Research Institute, Kenya
• Yale University, USA
  

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