Management of patients with Viral Hemorrhagic fever

Tauseef Akhund Research Officer Paediatric Department. Agha Khan University Karachi Pakistan

Introduction

Viral hemorrhagic fever (VHF) is the illness caused by geographically restricted viruses. Many viruses cause this illness but four viruses including Lassa, Marburg, Ebola, and Crimean-Congo hemorrhagic fever (CCHF) has potential of presenting in outbreak and has potential of person-to-person transmission. Among these four viruses, CCHF is endemic in certain parts of Afghanistan & Northern Pakistan. In September & October of each year we do get referral of patients with diagnostic possibility of CCHF. Since most physicians have little or no experience with these viruses, uncertainty often arises when VHF is diagnostic possibility.

These guidelines review the clinical and epidemiologic features of CCHF, provide recommendations on diagnosis, investigation, and care of patients, and suggest measures to prevent secondary transmission.

Crimean-Congo Hemorrhagic fever

CCHF virus is an enveloped, single-stranded Bunyaviridae. Many wild and domestic animals act as reservoirs for the virus, including cattle, sheep, goats, and hares. Ixodid (hard) ticks act both as a reservoir, and vector for CCHF virus.

CCHF is endemic in Eastern Europe, particularly Soviet Union, Northwest China, Central Asia, Indian subcontinent, Middle East and Africa.

 Transmission:

Humans become infected by being bitten by ticks or by crushing ticks, often while working with domestic animals or livestock. Contact with blood, secretions, or excretions of infected animals or humans may also transmit infection. In endemic areas, the disease may occur most often in the spring or summer

 Nosocomial Transmission is well described in reports from Pakistan, Iraq, Dubai, and South Africa. Available evidence suggests that blood and other body fluids are highly infectious, but simple precautions, such as barrier nursing, effectively prevent secondary transmission.

 Clinical Features:

The incubation period is about 2-9 days. Initial symptoms include fever, headache, myalgia, arthralgia, abdominal pain & vomiting. Sore throat, conjunctivitis, jaundice, photophobia, and various sensory and mood alterations may develop. A patechial rash is common and may precede a gross and obvious hemorrhagic diathesis. The estimated case-fatality rate is 15-70%. Symptoms & signs supporting the diagnosis of VHF are pharyngitis, conjunctivitis, and later hemorrhage & shock.

 Laboratory features: Deranged LFT, leucopenia, thrombocytopenia, and anemia.

 Diagnosis: Suspected on basis of epidemiologic risk factors, clinical features and non-specific laboratory abnormalities. Illness is confirmed by isolating the virus by PCR from blood during the first week of illness or by demonstrating IgM antibody or a fourfold rise in IgG. Antibody may not appear in blood until the second week of illness.

 Treatment: Ribavirin 30 mg / kg loading dose then 16 mg/kg q6h  x 4 days then 8 mg/kg q6h x 6 days. Supportive care and may require intensive care.

 Prophylaxis for high risk contacts is Ribavirin 600 mg po q6 h x 7 days

 Approach to a suspected case of VHF:

 General Principles;

·     Case identification:

o     Patient should be classified as probable if

1. Temperature of 101F (38.3C) or greater for < 3 weeks duration

2. Bleeding diathesis without predisposing factors for hemorrhagic manifestations

3. leucopenia or thrombocytopenia

o       Patient should be classified as possible if

1. Temperature of 101F (38.3C) or greater for < 3 weeks duration

2.  leucopenia or thrombocytopenia

 If clinician feels that VHF is likely (probable) diagnosis, they should take two immediate steps

1.      Isolate the patient

2.      notify infection control service

                                                 All other patients with possible diagnosis should be kept on standard blood and body fluid precautions

 Definition of Contact  A               contact is a person who has been exposed to an infected person  or to an infected person’s secretions within three weeks of the patient’s onset of illness.

Contact may be:

  Casual contacts are people on the same aero plane or in the same hotel. No special attention is required.

 Close contacts are defined as those family members living with patient or health

            Care workers coming into close contact with patient blood and body fluids. When

            the Diagnosis is confirmed, they should be placed under surveillance for three

            weeks.

        High-risk   contacts are those with:

Mucous membrane contact with the patient (kissing, sexual intercourse), health care worker who has done CPR, intubations or line placement without precautions. Needle-       stick or other penetrating injury. These contacts should be placed under surveillance as soon as VHF is considered to be a likely diagnosis in the index patient. Any contact that develops a temperature 38.3⁰C or higher or any other symptoms of illness should be immediately isolated and treated as a VHF patient. Ribavirin should be prescribed as post-exposure prophylaxis for

High-risk contacts of patients with CCHF

Isolation of patient with suspected and confirmed VHF:

 General principles:

ü      The patient should be isolated in single room with adjoining anteroom if possible. The anteroom should contain supplies for routine patient care as well as gloves, gowns and mask

ü      If possible, the patient’s room should be at negative air pressure

 

ü      Strict barrier nursing techniques should be enforced. All persons should wear disposable gloves, gowns, masks, and shoe covers. Double gloving is recommended in actively bleeding patients.

• Protective eye wear should be worn for persons dealing with disoriented or uncooperative patients or performing procedures that might involve the patients vomiting or bleeding (for example inserting the nasogastric tube or intravenous or arterial line).

• Protective clothing should be donned and removed in anteroom

• Isolation signs listing necessary precautions should be posted outside the anteroom

• Hand washing with antiseptic solution (betadine) before and after leaving the room

• Soiled Linen should be double bagged at the site of use and laundered with normal hot water cycle with bleach. Gowns, gloves and mask should be worn by laundry worker during handling the soiled items

• Patient care equipment e.g. thermometer, blood pressure apparatus stethoscope, should be dedicated to the patient. All non-disposable autoclave able equipment should be autoclaved after soaking in disinfectant

• The number of staff & visitors should be limited

• Suitable disinfectant solution include 0.5% sodium hypochlorite (10% aqueous solution of household bleach), and phenolic disinfectants (0.5%-3%). Soap and detergents can also inactivate these viruses and should be used liberally

 

Collecting Specimens

• Specimens from confirmed or suspected cases should be regarded as highly infectious

• All routine (UNIVERSAL) precautions should be taken.

• Specimens should be collected in a tightly sealed, screw-top plastic container

• Specimens and request form should be labeled with the patient’s details.

• Specimens and request form should be flagged with BIOHAZARD sticker   

• The outside of each container should be swabbed with disinfectant.

• The specimens should be double-bagged in secure, airtight and watertight bags that     have been similarly labeled.

 

Transporting and Packaging Specimens

• The watertight, primary container with the specimen (no greater than   50 ml)

• Specimens should be wrapped in sufficient absorbent material to soak up the contents if a breakage occurs.

                                   Specimens  

•  Laboratory staff dealing with specimens from patients who might have VHF must wear surgical gloves, gowns, shoe-covers and masks.

 Handling of dead body:

The same precautions recommended for clinicians and laboratory staff working with infected patients and specimens must be followed. Double gloves caps and gowns, waterproof aprons, shoe covers, and protective eye wear are required. All unnecessary handling of the body, including embalming should be avoided. The corpse should be placed in airtight bag and cremated or buried immediately.