Quick start guide - Community Health Global Network
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Ebola & Marburg Outbreak Control Guidance Manual Version 2.0 Peter Thomson MSF 2007 CONTENTS Foreword/Preface 7 Acknowledgements 8 Acronyms and Abbreviations 9 1 QUICK START GUIDE 10 1.1 1.2 1.3 Intervention Objectives Top Ten Priorities in an Ebola or Marburg Outbreak Starting the Intervention 10 10 14 2 Filovirus Background 23 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 A Brief History of Ebola and Marburg Disease Characteristics Virus Characteristics Natural Reservoir Transmission Pathophysiology Symptoms Incubation Period Laboratory Tests Previous Known Outbreaks MSF Experience Filovirus Outbreaks as a Global Social Phenomenon 23 23 24 24 24 25 25 26 26 27 28 28 3 Outbreak Management 29 3.1 3.2 3.3 Introduction Key Actors Involved in Outbreak Response The Importance of Coordination & Integration of All Elements 29 29 30 4 Epidemiology 31 4.1 4.2 4.3 4.4 Introduction Principles of the Epidemiological Response Surveillance Activities Data Management 31 31 32 37 5 Set-up, Installation and Organisation of Isolation Facilities 43 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Isolation Principles Isolation Options Cultural, Social and Psychological Factors Health Structure-Based / Independent VHF Treatment Unit Site Selection Considerations for VHF Treatment Unit Risk Zones VHF Treatment Unit Planning & Layout Installation of the VHF Treatment Unit 43 44 46 48 48 50 52 55 6 Hygiene & Infection Control in Outbreak Control Activities 57 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Barrier Nursing and Infection Control Personal Protective Equipment (PPE) Physical Barriers and Limiting Movement Disinfection Water Supply Sanitation Waste Management 57 57 61 61 64 65 66 2 7 Health Structure Based VHF Patient Management 69 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10 Introduction Rehumanising the Patient Admission Patient Flow Medical care Nursing Care Children Maternity Discharge Procedures and Continuing Care Isolation Ward Management 69 70 70 72 72 80 84 85 86 88 8 Home-based Support and Risk Reduction 91 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 Introduction Recommendations Patient Flow Information Flow Information Management Reducing the Risk of Contamination Case Management Burials Human Resources 91 92 93 94 95 95 96 97 97 9 Infection Control outside the VHF Treatment Facility 99 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10 9.11 9.12 9.13 9.14 9.15 9.16 9.17 Introduction Assessment and Intervention Criteria Hospital Infection Control and Triage Restriction of Hospital Services and Closure of Departments Triage and Early Detection of VHF Patients Detection of Patients after Admission Transfer of Suspect Cases to the VHF Treatment Unit Deaths Occurring in the Hospital Standard Precautions and Training of Staff Patient Placement Visitor Access and Precautions for Patients’ Attendants Medical Protocols and Reduction of Invasive Procedures Water Supply Peripheral Health Centres Laboratory Services Vaccination Traditional Healers and Birth Attendants 10 Safe Burials, Disinfection, and Ambulance Services 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 10.9 Introduction Cultural and Social Factors Involvement of Traditional and Community Leaders Communication Security Information Flow Adapting Procedures Logistics Human Resources 117 117 118 118 118 119 119 121 122 11 Socio-cultural Issues and Health Promotion 123 11.1 11.2 11.3 11.4 Introduction First Phase Examples of Content for 1st Phase Messages Second Phase – In-depth Cultural & Social Information and Analysis 99 99 100 102 103 106 107 107 108 111 111 112 113 113 114 115 115 117 123 123 124 125 3 11.5 Changing Risk Behaviours 126 12 Psychological and Social Support 128 12.1 12.2 Main Objectives Mental Health and Psychosocial Activities 128 129 13 Logistics 13.1 13.2 13.3 13.4 13.5 13.6 Emergency Preparedness General Logistic Support Treatment Unit(s) Expatriate Housing MSF Cars & VHFs The Kits: Composition, Use, and Logic behind Them 14 Human Resources 14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 14.9 14.10 14.11 Expatriate Staff National Staff Shifts & Breaks Staffing Needs for a 10bed / 50bed Treatment Unit Expatriate Life Expat Health National Staff Health Length of Stay/Working on Outbreak Control Activities Evacuation Procedures Job Descriptions Stress and Psychosocial Wellbeing 15 The End of the Epidemic 15.1 15.2 15.3 Removing Service Restrictions End of MSF Intervention Closing Down the Treatment Unit 16 Other MSF Projects in Areas Experiencing a VHF Outbreak 16.1 16.2 Projects within the Outbreak Area Projects outside the Outbreak Area 17 Ethical and Human Rights Issues Relevant to VHF 17.1 17.2 17.3 17.4 Experimental Drugs and Procedures Patient Consent and Confidentiality The Role of the Military in Outbreak Control Interventions Mass Quarantine of Populations 18 Dealing with the Media 157 Annex 1 Filovirus Information 158 Annex 1.1 Annex 1.2 Understanding Filoviruses Diagnosing Filoviruses Annex 2 Sample Collection and Transportation Annex 2.1 Annex 2.2 Annex 2.3 Collection of Confirmatory Samples Transportation & IATA Regulations Standard Form for Submitting Laboratory Samples Annex 3 Anthropological and Social Issues Annex 3.1 Rapid Assessment Checklist 132 132 132 133 135 135 136 138 138 138 139 139 140 140 141 141 142 144 144 149 149 149 149 152 152 152 154 154 154 155 155 158 159 162 162 163 167 168 168 4 Annex 3.2 Information Leaflets & Posters from Previous Outbreaks – English Versions Annex 4 Site Assessments and Planning Annex 4.1 Annex 4.2 Annex 4.3 Annex 4.4 Annex 4.5 Annex 4.6 Site Assessment Form for Health Centres Example of Plan of Isolation Facility Example of Plan of Changing Rooms Examples of Layouts of Previous Isolation Facilities Summary of Facilities in Different Risk Zones Waste Disposal & Pits Annex 5 Infection Control and Personal Protection Annex 5.1 Annex 5.2 Annex 5.3 Annex 5.4 Annex 5.5 Annex 5.6 Annex 5.7 Annex 5.8 Annex 5.9 Annex 5.10 Annex 5.11 Annex 5.12 Annex 5.13 Annex 5.14 Barrier Nursing Principles Dressing & Undressing Protocols Standard Precautions Additional Precautions to Reduce VHF Transmission Establish Routine Hand Washing Sharps Control Checklist for Patient Items Provided at Admission Management of Accidental Exposure Waste Management Preparation of Chlorine Solutions Maintaining Chlorine Sprayers Transferring Material Into & Out of the Treatment Unit Cleaning & Disinfection of Protective Equipment Infection Control Checklist for VHF Treatment Unit Annex 6 Medical Treatment Annex 6.1 Annex 6.2 Annex 6.3 Annex 6.4 Example Treatment Protocol for VHF Systematic Treatment Protocol Malaria Treatment during VHF Outbreaks Maternity and Delivery Guidance Annex 7 Data Collection & Operational Research 214 Annex 8 Health Centre Outreach and Assessment Activities 215 Annex 8.1 Annex 8.2 Outreach Guideline: Health Centres Assessment Team Guideline Annex 9 Home Based Support and Risk Reduction Annex 9.1 Annex 9.2 Annex 9.3 Implementation of Home Based Support and Risk Reduction Caretaker Task Instructions Information to Be Given To the Families Annex 10 Mental Health and Psychosocial Components Annex 10.1 Annex 10.2 Psychosocial Activities and Patient Flow Distribution of Solidarity Kit Annex 11 Ambulance and Burial Services Annex 11.1 Annex 11.2 Annex 11.3 Annex 11.4 Annex 11.5 Annex 11.6 Checklist: Supplies for Ambulance Teams Checklist: Supplies for Burial Teams Guideline for Safe Burial Practices Procedure to Clean VHF Ward after a Death Example of Culturally Adapted Pre-Burial Body Washing Procedure for House Disinfection Annex 12 Medical and Epidemiological Forms 170 175 175 177 178 179 182 187 188 188 189 194 195 196 197 198 199 200 201 202 204 205 207 209 209 210 210 213 215 216 218 218 220 222 223 223 223 226 226 227 228 230 231 232 233 5 Annex 12.1 Annex 12.2 Annex 12.3 Annex 12.4 Annex 12.5 Annex 12.6 Annex 12.7 Annex 12.8 Triage Form Medical Admission Form Observation Sheet HBSRR Follow Up Sheet VHF Treatment Sheet Contact Tracing Form Contact Recording Form Epidemiological Form 233 234 237 238 240 241 242 243 Annex 13 Information for Patients, Discharged Patients, & Relatives 247 Annex 14 Staff Training – VHF Treatment Unit and Health Centres 249 Annex 14.1 Annex 14.2 Example of Training Module for VHF Treatment Unit Personnel Example of Training Module for Health Centres Annex 15 Job Profiles and Task Descriptions Annex 15.1 Annex 15.2 Annex 15.3 Annex 15.4 Annex 15.5 Annex 15.6 Annex 15.7 Annex 15.8 Annex 15.9 Annex 15.10 Annex 15.11 Annex 15.12 Annex 15.13 Annex 15.14 Annex 15.15 Annex 15.16 Annex 15.17 Annex 15.18 Annex 15.19 Data Collector for Mortality Surveillance Data Collector for the Treatment Unit Doctor in Charge of the VHF Treatment Unit Doctor on Duty in the VHF Treatment Unit Head Nurse of the VHF Treatment Unit Water, Sanitation and Hygiene Coordinator Nurse – VHF Treatment Unit Watsan – VHF Outbreak Control Laundry Person / Chlorine Solution Maker – Low-risk Zone Waste Collector/Burner Cleaner – High-Risk Zone Guard – Changing Room 1 Psychological & Psychosocial Coordinator Psychologist for Inpatient Activities Community Activities Psychologist Health Promotion/Social Mobilisation Coordinator Example of Ambulance Team Task Description Example of Burial Team Task Description Example of VHF Ward Support Staff Task Descriptions Annex 16 Main Intervening Organisations in Filovirus Outbreaks Annex 16.1 Main Filovirus Testing Centres Annex 17 Contents of Viral Haemorrhagic Fever Kits Annex 17.1 Annex 17.2 Annex 17.3 Assessment Kit – Locally Composed Health Centre Kit Home Based Support and Risk Reduction Kit 249 251 253 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 271 273 275 276 278 289 291 292 Annex 18 Quality and Requirements for Protective Equipment 293 Annex 19 Glossary 295 Annex 20 Bibliography 297 6 Foreword/Preface This manual is intended to be a simple and practical tool to aid in designing and carrying out an Ebola or Marburg outbreak control programme. It provides background information and practical guidance on all aspects of an intervention to manage and control an outbreak of these diseases. The manual is relevant for all staff working on an outbreak control intervention, including project coordinators; medical and paramedical staff; water and sanitation staff; epidemiologists; health promoters; psychosocial staff; and logisticians. The manual provides guidance for the implementation of the following stages of an intervention: - Assessment of an outbreak and the context in which it occurs. - Identification and design of appropriate responses. - Implementation of the outbreak control measures. - Closing down of the intervention. In addition, this guide will provide technical information for those responsible for the supervision and training of staff. This manual is divided into 18 Chapters covering all aspects of the intervention. The Annexes are grouped by topic and contain further explanation, background reading, detailed descriptions of procedures and protocols, forms, checklists, job descriptions, etc. Background information, images, film clips, and supporting documents and guidelines are available on the accompanying CD. Throughout the document, the terms VHF (viral haemorrhagic fever) and filovirus are used interchangeably to refer to Ebola and Marburg diseases. If viewing this document in MS Word, navigation can be facilitated by using the “forward” and “back” buttons on the Web toolbar; select View > Toolbars > Web. Ebola and Marburg interventions are evolving fields. To enable future updating of the manual, any suggestions and critical comments are welcome. Comments and suggestions should be addressed to armand.sprecher@brussels.msf.org. 7 Acknowledgements This manual has evolved from the work and contributions of many, many people. There are the people who have made remarks or suggestions in the field, the people who compiled and wrote reports of their work that contributed directly to this manual, and of course, those who provided input, reviewed, and commented during the writing of the document. If your name has been missed, and you feel it should be below; please accept humble apologies and rest assured that it was not omitted on purpose. Zohra Abaakouk Raquel Ayora Peter Bech Larsen Vincent Brown Marie Eve Burny Jean De Cambry Monica Castellarnau Xavier De Radrigues Evelyn Depoortere Katharine Derderian Claire Dorion Luis Encinas Annick Filot Benjamin Jeffs Christian Katzer Aurelie Lamaziere Genevieve Loots Peter Maes Nicola Main-Thomson Veronique Mulloni Paul Roddy Pepa Rodríguez Angela Rose Armand Sprecher Luis Villa David Weatherill Zoe Young 8 Acronyms and Abbreviations AZG CDC-Atlanta EHF ELISA GI GOARN HEPA-filter HF HRM HTH IATA IEC IG IgA, IgG, IgM IM IV KAP MHF MSF ORS PCR PO PPE PPI TBA UV VHF WHO Artzen Zonder Grenzen (i.e. MSF) Centers for Disease Control-Atlanta Ebola haemorrhagic fever Enzyme-linked immunosorbent serological assay Gastrointestinal Global Outbreak Alert and Response Network High efficiency particulate – filter Haemorrhagic fever Human resource management High Test Hypochlorite (chlorine granules) International Air Transport Association Information Education Communication (now called Health promotion) Immune globulin Immunoglobulin classes Intramuscular Intravenous Knowledge Attitude Practice Marburg haemorrhagic fever Médecins Sans Frontières, Médicos Sin Fronteras Oral rehydration solution Polymerase chain reaction By mouth Personal protective equipment Proton pump inhibitor Traditional birth attendant Ultraviolet Viral haemorrhagic fever World Health Organisation 9 1 QUICK START GUIDE This section briefly summarises the issues, actions, and interventions that must be considered when dealing with an outbreak of Ebola or Marburg viral haemorrhagic fever. It provides a brief introduction and outline of an intervention, and all aspects are dealt with in detail in the main part of the document. All persons involved in the outbreak control activities must read this section. 1.1 Intervention Objectives There are two objectives in dealing with an outbreak of Ebola or Marburg: To provide a decent level of care to the patients. To reduce and contain the spread of the disease. 1.2 Top Ten Priorities in an Ebola or Marburg Outbreak The foremost priority is to think! Think about what you are doing: Why are you doing it? How should you do it? Understand why you should perform tasks in a certain manner. Understand what the repercussions can be of performing tasks in another manner. This guide, and the protocols and procedures described will help in implementing the outbreak control activities. However, do not follow everything blindly; every situation will be different with its own particularities and peculiarities, and will require adaptations and adjustments. It is important that the rationale for doing certain things, and performing tasks and activities in a specific manner is understood. Then, when unforeseen situations arise, the situation can be managed and procedures can be adapted safely, or another solution can be found. Top Ten Priorities to Start the Intervention Most of the activities can and should be done concurrently. 1. Protect Yourself 2. Collect and Analyse Information 3. Coordinate 4. Decontaminate 5. Care For Existing VHF Patients 6. Communicate 7. Identify and Train Staff 8. Plan and Start Installation of Isolation Unit 9. Organise Patient Identification and Transportation 10. Ensure Safe Practices in Other Health Services 10 1.2.1 Top Ten Priorities in More Detail 1. Protect Yourself a. Organise protective material: When arriving in an affected area, it is crucial to take the time to organise the team with ready access to Personal Protective Equipment (PPE), disinfection and other materials; keep stocks in the house, the office, and the cars. Prepare “Mini-kits” of complete individual protective clothing and disinfection materials, and carry in all cars. b. Reinforce team PPE training: Ensure that all members of the team know when the use of protective gear is required and how to put it on and take it off correctly. Practice the procedures repeatedly in a “safe area”. See Annex 5.2 Dressing & Undressing Protocols. c. Be vigilant for contamination: In the first phase it is not always possible to know what is, or may be, contaminated. Therefore, prudence and extreme care is required, especially while carrying out initial assessments. d. Be alert for and manage stress: Stress affecting the team and individuals can be a major problem. Be vigilant for signs of stress and manage stress when it arises. Ensure that all team members take regular breaks: having sufficient rest and eating well can contribute to avoiding and reducing stress. For further information on stress issues, see section 14.11 on Stress and Psychosocial Wellbeing. e. Clean and disinfect accommodations: Ensure the team accommodation is kept clean and routine disinfection is done with chlorine solutions. Install a hand washing and disinfection station at the entrances to the office and the accommodation. f. Prevent the team members from getting ordinary diseases: During an epidemic, every illness is open to misinterpretation causing significant stress. In malaria risk areas (endemic and epidemic), the use of bed nets and malaria prophylaxis is mandatory. Enforce good hygiene measures to prevent gastrointestinal and respiratory illnesses (e.g. wash food carefully and do not overcrowd living quarters). 2. Collect and Analyse Information The initial assessment and the collection and analysis of data provide the basis for determining the intervention strategy. It is important to collect sufficient reliable information while avoiding wasting time and delaying the initiation of actions. a. Begin epidemiological investigation: Examine the (possibly limited) patient information and data that is available to get an indication of the number of people who have been infected, where they were infected, who infected them and to whom they may have transmitted the disease. This analysis will help in focusing efforts in the most effective direction. i. Coordinate with other epidemiological actors: MOH, WHO, etc. ii. Initiate Contact Tracing and Case Finding. For further information, see Chapter 4 on Epidemiology. b. Assess health structures: Assessments of the health structure(s), the staff and their capacity, hygiene and infection control measures, etc. is crucial. See Annex 4.1 Site Assessment Form for Health Centres. c. Perform local anthropological assessment: Investigate the prevailing cultural, social, and anthropological context, and the beliefs and practices that could affect control of the outbreak. These issues may include traditional disease explanation models; traditional health practices; beliefs and practices linked to death and bereavement; relationships between different social, religious, political and ethnic groups. For further information, see Chapter 11 on 11 3. 4. 5. 6. Socio-cultural Issues and Health Promotion, and Annex 3.1 Rapid Assessment Checklist. d. Acquire background anthropological information: At headquarters, carry out a desk study of the anthropological social and cultural issues pertinent to the area and populations affected. There is likely to be a significant amount of information available, especially within the academic world. There are known anthropologists with VHF experience to call upon also. e. Identify local organisations: There may be organisations with a history of working with the affected population; these organisations and their staff can often be a valuable source of information, and can give insights into the possible opportunities and constraints that could affect the intervention. f. Identify other actors: It is crucial to understand what the different actors are planning to do, when they will do it, and whether they actually have the capacity. Other actors that may be present and active will include the hospital staff and management, the national/regional health authorities, national crisis group, community and religious leaders, WHO, Epicentre, CDC, Health Canada, Red Cross societies, etc. For contact details of some organisations, see Annex 16 Main Intervening Organisations in Filovirus Outbreaks. Coordinate a. Communicate and coordinate with other actors: Ensure that the implementation of all aspects of the outbreak intervention occurs at the right time, in the right place and in the right way. For example, it may be counterproductive to initiate strict burial procedures before health promotion/social mobilisation activities are implemented, and the communities understand why such measures are necessary. b. Consult and inform other organisations: There may be NGOs, faith based and other organisations working in the affected area. It is likely that these people will have built up trust with the community, and they will have experience and knowledge of the area and the population. i. They are a resource for acquiring information, and can assist in providing trusted information to the community. This is especially true for those working in the health sector. ii. Consult them, and inform them about the intervention and the measures taken. Provide support and training where necessary. Decontaminate a. Implement immediate decontamination activities: Prepare and arrange protective equipment, disinfection materials, waste disposal/temporary storage locations, and define procedures for the immediate decontamination activities. b. Dispose of any obvious source of virus that may be present: e.g. dead bodies, and contaminated waste, etc. See Annex 11.3 Guideline for Safe Burial Practices, and Section 6.7 Waste Management. c. Disinfect contaminated areas: Clean and disinfect all potentially contaminated areas, buildings, and equipment. See Section 6.4 Disinfection. Care For Existing VHF Patients a. Arrange a basic set-up for patient care: Provide PPE, disinfection solutions and waste collection/storage to allow safe entry into the patient area, safe patient care, and safe exit from the area. See Chapter 5 Set-up, Installation, and Organisation of Isolation Facilities. b. Provide care for VHF patients that are already admitted. See Chapter 7 Health Structure Based VHF Patient Management. Communicate 12 Outbreaks of Ebola and Marburg create great fear and uncertainty. The affected population demand and need information in order to understand the disease and to feel reassured. If there is a lack of relevant and accurate information reaching the communities, hearsay, rumour, conjecture, and potentially dangerous misinformation will fill this information vacuum. Therefore, it is crucial to create and/or increase community knowledge and awareness of the disease. Provide relevant and appropriate information to the affected populations as quickly as possible. a. Inform the population about the disease: i. The disease and the alarm signs. ii. How to avoid transmission. iii. What to do if they suspect they have the disease. iv. Where they should go if they suspect they have the disease. v. Why the unusual protective clothing and infection control measures are necessary. b. Inform the population about the outbreak control activities: i. Overview of MSF, and the activities MSF and other actors will carry out. ii. Types of medical care that will be provided. iii. Reasons for strict infection control methods. iv. Reasons for isolation of patients in special accommodation areas. c. Messages and their delivery must be adapted to the socio-cultural context. For further information, see Chapter 11 on Socio-cultural Issues and Health Promotion. 7. Identify and Train Staff Training is crucial; immediately start an initial basic training of staff. a. Identify staff: identify whom you can work with, and the number of staff (medical and non-medical) required immediately, and in the longer term. See Section 14.4 Staffing Needs for a 10bed / 50bed Treatment Unit. b. Train staff: organise training of healthcare staff, cleaners, epidemiological staff, burial teams, and ambulance and mobile teams. See Annex 14 Staff Training – VHF Treatment Unit and Health Centres. c. Devote sufficient attention to training and coaching: All staff working in an isolation unit or in the mobile teams must understand what they are required to do and the risks their work entails; therefore sufficient time, attention, and effort must be devoted to the training and coaching of staff. d. Train domestic staff: All staff working in the team accommodation must be trained in the specific hygiene measures required. e. Identify and arrange a training area: Training of staff is an ongoing activity, and it is likely that large numbers of staff will receive training; therefore, provide an area specifically for training. 8. Plan and Start Installation of Isolation Unit a. Keep it simple. b. Determine the best isolation options for the outbreak: Possibilities include isolation unit(s) in hospital(s); isolation unit(s) not associated with hospital(s); and home care support. For further information, see Section 5.2 on Isolation Options. c. Identify and arrange temporary isolation facilities to use while installing and starting implementation of the chosen option. d. Plan for safety: All installations, facilities, procedures, and circuits must be safe, they must minimise the risk of accidents, and they must be straightforward to understand and use. See Annex 4 Site Assessments and Planning. 13 e. Plan flexibly and dynamically: Bear in mind that as the intervention proceeds, it may be necessary to change or adjust the isolation option and initial strategy employed at the start of the outbreak. f. Ensure reliable and timely supply of all necessary equipment and materials. 9. Organise Patient Identification and Transportation a. Organise triage of patients: Ensure rapid and efficient triage of patients to immediately identify and admit suspect cases when they arrive at the hospital or the isolation unit. Likewise, non-VHF cases must be quickly identified and leave the triage area and proceed to the appropriate hospital department. i. In small health structures, a single triage area may be adequate. However, in larger structures, triage areas may be necessary in both the isolation unit and the hospital itself. ii. Special attention may be required for the maternity department, where another separate triage area can be considered. See Section 7.3 Admission. b. Organise ambulance and burial teams: Train the teams and ensure they are operating as quickly as possible. i. Take care in selecting staff for these teams, and with their training; they must be diplomatic, culturally sensitive, calm, patient, and knowledgeable about the disease. The burial and ambulance teams may be one of the first points of contact with a family and the community, and often act as the “ambassadors” of the intervention. ii. Do not delay removing bodies from the community, hospital morgue, etc. The strict protocols applied to the handling and burials of bodies are difficult to accept for many societies, therefore investigate the traditional practices related to death so that the preparation of the body and the burial can be adapted to the cultural needs and the grieving process without compromising safety. See Chapter 10 Safe Burials, Disinfection, and Ambulance Services. 10. Ensure Safe Practice in Other Health Services a. In healthcare facilities, investigate the need to suspend unnecessary surgery and laboratory tests, and introduce or reinforce standard precautions. b. In the community and informal health services, discourage unsafe amateur injections, and other high-risk interventions. See Chapter 9 Infection Control outside the VHF Treatment Facility. 1.3 Starting the Intervention Two scenarios are described: 1. There is a suspicion of an outbreak and MSF will participate in the investigation of the outbreak and subsequent outbreak control activities. 2. An outbreak has already been declared and MSF will participate in the outbreak control activities. 1.3.1 Initial Assessment An initial assessment is common to both scenarios. Where an outbreak has not yet been declared, the assessment will include investigating and confirming the outbreak. The initial assessment provides the basis for deciding whether to intervene and for subsequent operational decision-making particularly in the early stages of an intervention. Therefore, it is important to collect sufficient, reliable information without wasting time and delaying the initiation of actions. 14 If there is a suspicion of an outbreak (without confirmation), important questions that must first be answered are: Is there actually an outbreak of Ebola or Marburg? Has an outbreak been officially declared? Has there been a request for assistance? Is there a need for outside intervention and assistance, and is there a need for MSF to intervene and assist? Do the political, logistical, and security contexts allow MSF to intervene and assist? The initial assessment must investigate the following key issues: Assessment and confirmation of case(s) through: o Clinical investigation based on case definitions. o Collection of samples and laboratory testing. Health structure(s) assessment: o Presence and functioning of administration, management, and direction. Capacity to manage? o Inventory and survey of buildings, services, state of infrastructure, etc. Inventory of materials and equipment available. Survey of water supply and sanitation facilities. Survey of waste management facilities and practice. Case management assessment. o Presence of medical and non-medical staff? Type of staff present and available? Capacity of staff? o Presence of non-VHF patients? Where and what types? o Presence of VHF patients? Where accommodated? State of isolation facilities if present? Social-cultural-anthropological initial assessment. o Determine how the community perceives the current epidemic and what they believe to be happening. o Determine the main ethnic and religious groups living in the affected area, and any possible tensions between the different groups. o Determine the structures of official and traditional power frameworks. o Identify the community leaders – traditional, political, official, and religious. o Investigate the community’s perception of isolation, and its acceptability. o Investigate the traditional beliefs and practices linked to ill health. o Investigate the availability and use of traditional health care services, and the forms that they take. Identify any potentially dangerous practices. o Investigate the traditional beliefs and practices linked to death and mourning. Identify any dangerous practices. Logistics and Security Assessment o Is it possible to access the affected areas? What types of transportation facilities are required and available? Will travel and transportation constraints affect the intervention? o Survey the local market and identify equipment and materials that are available. o Investigate the possibilities for freight transportation and storage. o Does the security situation permit access to the affected areas? Is it possible to travel freely? Are there specific threats? 15 1.3.2 Assessment of Cases and Confirmation of the Outbreak Clinical Investigation Clinical diagnosis of Ebola and Marburg is notoriously difficult. Many of the symptoms are non-specific and a patient may present with symptoms that are very similar to common tropical diseases e.g. malaria, shigellosis and typhoid fever. Outbreaks are usually suspected after a number of suspicious deaths of patients with haemorrhagic symptoms rather than by applying the usual case definition, which is very non-specific. Case definitions are most useful once an outbreak has been confirmed. See Section 4.3 Surveillance Activities - Case Definitions. Confirmation of cases is necessary before an outbreak is declared. This confirmation can only be done through laboratory testing, and testing can only be done at a small number of laboratories that are equipped with Bio-safety Level-4 (BSL-4) facilities. (For contact details of BSL-4 laboratories, see Annex 16.1 Main Filovirus Testing Centres). Confirmatory testing is done on blood samples or, less often, on post-mortem skin specimens. Blood samples and skin specimens must be collected according to strict protocols. Collection of Samples (For more information, see Annex 2 Sample Collection and Transportation. The collection of samples from patients suspected to be suffering from a filovirus infection requires the use of strict protective and disinfection measures. The collection of samples should only be attempted when safety is assured. The Sampling and Assessment module (Module 7) of the standard MSF Ebola Haemorrhagic Fever Kit contains all materials and equipment necessary for safely carrying out an assessment: examining patients; collecting samples; and packaging and transporting the samples according to IATA regulations. The Sampling module (Module 5) contains only the sampling and transportation material. An explanation of the items used for the different sampling methods is given in the module lists and descriptions. See Annex 17 Contents of Viral haemorrhagic Fever Kit. Important Points Before taking any samples, identify and inform the receiving laboratory. Notify the laboratory that suspected filovirus samples are being sent to them before dispatch. It is essential to follow protocols for sampling to ensure that the samples will be useful and valid. A clinical description of the suspect case(s) should accompany all samples. All samples must be safely packaged using a triple-packaging system, and stored and transported according to protocols. All used sampling equipment and material must be disposed of safely. 1.3.3 Reinforcement of Standard & Additional Precautions in Health Structures Introduce or reinforce standard precautions in all health facilities in the area (including private). This is a priority to avoid further nosocomial amplification in the health facilities. This can be started while awaiting confirmatory lab results. Investigate the level of risk for the different hospital activities, and temporarily reduce or stop non-lifesaving surgical interventions and lab tests. 16 Standard Precautions Standard Precautions (also called Universal Precautions) are basic infection control measures, and are a minimum standard in every health structure. Standard precautions require that health care workers assume that the blood and body substances of all patients are potential sources of infection, regardless of the diagnosis, or presumed infectious status. 1. Wash hands Before and after touching a patient. After any contact with body fluids. Prepare container of clean water, basin, soap-dish, waste bin, and disposable towel (or air-dry hands). 2. Wear gloves If there is contact with body fluids, broken skin or mucous membranes. Remove gloves, discard in waste bucket, and wash hands after each use. 3. Routine cleaning with soap or detergent Of beds, bedside tables, examination tables. Of floors, latrines and bathing areas, etc. 4. Handle needles and sharps safely. Avoid separating needles from syringes. Put needles and sharps in puncture resistant sharps container. Do not re-cap needles. Do not re-use needles or syringes. Dispose of sharps container in sharps pit. 5. Safe disposal of spills and waste Remove with cloth. Wash area with soap and water or detergent or chlorine solution and leave to dry. 6. Wear mask & goggles The eyes, nose, and mouth are the most vulnerable part of the body; therefore, protection is necessary especially if a splash is likely. Additional precautions are required for diseases transmitted by air, droplets, and contact. These are termed “additional (transmission-based) precautions”, and specific precautions to reduce VHF transmission are described below. Additional (transmission-based) Precautions to Reduce VHF Transmission in Health Structures Precautions to reduce VHF transmission in health structures must be applied in all regular health facilities within the suspected epidemic area as soon as VHF is confirmed. In the isolation unit, complete barrier nursing and infection control techniques will be used. These are explained in Chapter 6 Hygiene & Infection Control in Outbreak Control Activities. Additional precautions required for dealing with VHFs are as follows. 1. Isolate the VHF patient: Limit patient movement and restrict access to one trained patient attendant. 17 Cover mattress with reusable plastic sheet. Instruct attendant to avoid touching patient, and provide protective gear and training to attendant. 2. Avoid giving injections or taking blood. 3. Wear protective gear when touching/examining patient 4. Wear mask and goggles Especially if splash is anticipated or patient is coughing. 5. Safely dispose of contaminated materials: Use plastic bag receptacle for contaminated materials such as used latex gloves, or other disposable materials used by patient. Discard and burn contaminated materials. 6. Use disinfection procedures: Prepare 0.5% and 0.05% chlorine solutions. Disinfect the following items in 0.05% chlorine solution: i. Household gloves, aprons, goggles; ii. Medical equipment such as thermometers iii. Cups and dishes Disinfect gloved hands after contact with patient in 0.5% chlorine Disinfect patients excreta, vomit, urine: i. Add 0.5% chlorine to the container to cover contents and discard in latrine. ii. Wash container with soapy water and discard in latrine. iii. Rinse container with 0.5% chlorine (container may then be re-used). Disinfect spills of body fluids i. Cover completely with 0.5% chlorine solution ii. Let stand for 15 minutes. iii. Remove with rag or paper towels. iv. Discard rag in plastic bag for infected waste v. Wash area with soap and water. Disinfect patient clothing and bedding before laundering: i. Soak soiled clothing in 0.05% chlorine for at least 30 minutes. ii. Remove and place in a container of soapy water overnight, rinse thoroughly and dry on line. 7. Close laboratories and operating theatres to non-essential surgery until safe working is guaranteed. 18 1.3.4 Training Commence training of health staff on: Case definitions, clinical diagnosis, and recognition of suspect cases. Methods of transmission, and prevention of transmission. Implementation of Standard and Additional VHF Precautions. The use of protective clothing and barrier nursing techniques. Training can be started while awaiting confirmatory lab results. See Annex 14.1 Example of Training Module for VHF Treatment Unit Personnel and Annex 14.2 Example of Training Module for Health Centres. 1.3.5 Starting the Intervention If awaiting confirmatory test results, prepare contingency plans for possible intervention in case results are positive. Investigate possible locations for the installation of an isolation unit. Identify the needs in case an intervention has to be started. Ensure that a standard MSF viral haemorrhagic fever kit is prepared and on standby in Europe or in the region. Check availability of staff that could work in an isolation unit. ! Once an outbreak is declared (following laboratory confirmation), and MSF has decided to intervene and assist, order the MSF standard Viral Haemorrhagic Fever Kit. The three main intervention components that MSF will generally work on must be set up in parallel. 1. Epidemiology and Surveillance System 2. Case Management and Isolation 3. Health Promotion/Social Mobilisation The division of responsibility for the different components will depend primarily on the presence of other actors and the size of the outbreak. MSF is most likely to be responsible for the case management and isolation activities, but may also take responsibility for other components. All outbreak control activities must be coordinated and implemented correctly. essential to verify that all components and activities are implemented correctly. It is 1. Epidemiology and Surveillance System Main objectives of the surveillance system will be: Analysing patterns of epidemiological spread and guiding the control measures with this information. Establishing and coordinating active case finding, contact tracing and follow-up of contacts. Providing information on cases to ambulance, burial, disinfection, and social mobilisation teams. Disseminating regular information on the evolution of the outbreak. 2. Case Management and Isolation General principles are the following: 19 All suspect, probable, and confirmed filovirus patients must be cared for in a safe and dignified manner. The main objectives of isolating patients are to break the transmission lines, and to create a safe working environment to provide patients with supportive care. Ebola and Marburg are spread through direct contact with infected persons and their body fluids or contact with infected objects; therefore, barrier nursing techniques and strict infection control measures are essential. It is critically important that staff members working in an isolation unit are properly trained; therefore sufficient attention, time, and effort must be devoted to training and coaching of staff. See Annex 14.1 Example of Training Module for VHF Treatment Unit Personnel. 3. Health Promotion/Social Mobilisation The main aim is to give accurate and relevant information concerning the disease and the outbreak control activities to achieve the following: Create or increase community knowledge and awareness of the disease, and the outbreak control measures. Enable the community to recognise alert cases, and to take the appropriate action if they suspect someone is suffering from the disease. Reduce the risk of possible infections linked to traditional behaviours and practices. Avoid stigmatisation of health workers, suspect cases, discharged (and non-confirmed) patients. Other Important Components Apart from the three components mentioned above, other aspects that are essential to the control of an outbreak include: Ambulance and burial teams must be trained and operating as quickly as possible. Assessing, monitoring, and assisting all health providers for the implementation of Standard and Additional VHF Precautions. Avoid nosocomial amplification by ensuring safe practices in operating theatres, laboratories, and delivery rooms (include traditional birth attendants). Closure or reduction of non-essential services may be necessary. o Consider introducing safer surgery practice, techniques, and kits. 1.3.6 Human Resources In order to tackle all the tasks and activities a multi-disciplinary team is required, and depending on the scale of the intervention, can include the following: Field coordinator (depending on the situation, an assistant field coordinator may also be necessary. Two watsans for isolation setup, decontamination and mobile activities. Logistician /security coordinator. Infection control nurse. Mobile nurse. Health promoter. Isolation wards MD. Epidemiologist. HR Needs for Set-up Phase (1 week to 10 days) The installation of the isolation facilities and initial organisation of intervention activities can greatly influence the later day-to-day operations. A good initial set-up will facilitate the management and safe implementation of activities. It is highly recommended that staff 20 experienced in isolation, infection control and VHFs organise, guide, and manage the set up phase. An outbreak of Ebola or Marburg is still considered “hot” news. In the early phase of an intervention, there is likely to be significant attention from the press; if necessary, a contact person or press officer should be available to relieve the pressure on the teams. HR Needs for Day-to-Day Operations For the day-to-day activities inside the isolation unit, it is highly recommended that staff trained and experienced in barrier nursing organise and manage the activities, and supervise and train less experienced staff. General HR Considerations All staff must receive clear briefings, and understand the risks before starting work. See Annex 14.1 Example of Training Module for VHF Treatment Unit Personnel. All safety rules and protocols must be respected at all times; everybody has a responsible to monitor this, but specific responsibility lies with the staff in charge, and the safety officer. The stress engendered through developing a simple fever by a person working in a filovirus outbreak is enormous. Therefore, efforts must be made to reduce the risks of contracting other illnesses; malaria prophylaxis & the use of bed nets is mandatory in areas affected by malaria, and good domestic, personal and food preparation hygiene is essential. Similar measures should be encouraged and enabled for national staff working on outbreak control activities. All staff must take sufficient rest, especially those working on high-risk activities. A minimum should be one day off per week, and one weekend per month Organise activities so that a regular and reasonable routine can be established. For example, lab results should be available mid-afternoon to allow patient transfers etc. to be done on the same day during daylight hours. Stigmatisation of staff can be a major problem; therefore, make psychosocial support available to staff and their families. Safety Officer Identify a safety officer. Responsibilities include: All safety issues linked to the isolation activities. Assessing safety issues and deciding which activities can be implemented; also, the level of care that can be provided according to the level of safety achieved. Monitoring the implementation and adherence to safety measures. Evaluating the safety issues arising from untoward situations and deciding on the course of action to deal with them. The authority of the Safety Officer is similar to that of the MSF Security Coordinator. His/her decision is final at the particular time, but can later be discussed and reassessed. 1.3.7 Logistical Support Good logistical support is essential in an outbreak control intervention, and the logistics team will be involved in all aspects of the intervention. General Support o Housing, transport, food, water, etc. o Set-up and organisation of epidemiological base, isolation unit and linked activities, mobile teams. 21 o Ensure the correct application of the special rules and approaches concerning housing, vehicles, and security. Supply and security stocks o The reliable supply of protective equipment is a key issue. o Monitoring stocks and ensuring timely re-supply is essential; running out of just one protective item can result in the halting of activities. Back to Table of Contents 22 2 Filovirus Background This section provides an overview of the viral haemorrhagic fevers caused by filoviruses, i.e. Ebola and Marburg. It briefly explains the nature of these viruses, and the characteristics of the diseases. Primary audience: Medical staff. Secondary audience: All staff working on outbreak control activities. 2.1 A Brief History of Ebola and Marburg Ebola and Marburg are Viral Haemorrhagic Fevers (VHFs) caused by filoviruses (threadlike viruses). Ebola and Marburg epidemics have occurred in the forested, central belt of Africa where it is presumed that the reservoir or host species resides. Laboratory based outbreaks have occurred in a number of countries, usually associated with transmission from newly arrived infected monkeys. Ebola, named after a river in the Democratic Republic of Congo where an outbreak occurred in 1976. Marburg, named after a town in Germany where one of the first outbreaks occurred in a laboratory in 1967. 2.2 Disease Characteristics Human cases or outbreaks caused by these viruses occur sporadically and irregularly. Humans are not the natural reservoir, but can become infected when exposed to infected hosts; human-to-human transmission may then occur. There is no cure or established drug treatment for Ebola or Marburg; however, observation suggests that some patients respond to supportive therapies. Ebola and Marburg are two of the most virulent viral diseases known, causing death in 5090% of all clinically ill cases (mortality rate depends on the strain). Four different strains of Ebola have been identified: Africa: Ebola-Zaire (EBO-Z) – (Includes Ebola-Gabon) Ebola-Sudan (EBO-S) Ebola-Ivory Coast (EBO-CI) (= Ebola-Taï) Philippines: Ebola-Reston (EBO-R) Virus Families Causing Important Haemorrhagic Fevers Viral Haemorrhagic Fevers Filoviruses Marburg HF Ebola Zaire Ebola Sudan Bunyavirus Ebola HF Crimean Congo HF Ebola Ivory Coast Rift Valley HF Flavivirus Arenavirus Yellow Fever Lassa Fever Ebola Reston 23 2.3 Virus Characteristics The Ebola and Marburg viruses have a lipid (fatty) envelope that is relatively fragile and vulnerable to chlorine disinfection, heat, and direct sunshine (UV light). Soaps and detergent can also be effective in destroying the virus; they dissolve the fatty envelope, which results in its death. For simplicity and security, disinfection with chlorine solutions of 0.05% & 0.5% is the primary technique recommended. 2.4 Natural Reservoir At present, the natural reservoirs are unknown, but research points to the involvement of bats in both Ebola and Marburg transmission, and non-human primates have been implicated in outbreaks of Ebola. Monkeys and apes die quickly when infected with Ebola; therefore, it is unlikely that they act as the natural reservoir. However, infected bats can survive, and there is evidence of asymptomatic infection, which suggests that they may play a greater role, either as the natural reservoir or as an important transition species. 2.5 Transmission Human Reservoir Vector (Intermediate Host) Human Index case Human Human The virus enters into the human population when human activities bring about interaction and contact with infected reservoirs or hosts. Infection can occur through handling infected animals; the hunting of bush meat has been shown to be particularly risky and infection via contact with non-human primates and forest antelopes has frequently been documented. Research has shown that human outbreaks have often been associated with prior outbreaks and die-off in animal populations. In addition, it is thought that climactic variations may play a role in the propagation of an outbreak. Human to human transmission of both Ebola and Marburg occurs via direct contact with: Infected body fluids: blood, vomit, excreta, sweat, saliva, etc. Semen (Ebola virus-RNA has been found in semen up to 3 months after clinical recovery). Infected organs and body parts. Infected corpses. Contaminated materials. 24 Airborne transmission cannot be excluded; however, where infection has occurred without direct contact reported evidence points to transmission via droplets, aerosolised particles, and fomites. There is no evidence to suggest that transmission can occur during the incubation period. 2.6 Pathophysiology The virus can replicate in a large variety of human cells. Macrophages and dendritic cells are generally the first cell types to be infected, and the infection affects their functioning, inhibiting the presentation of antigens to lymphocytes, and interfering with the secretion of immune regulating factors. This causes an immune suppression. As the disease progresses parenchymal cells, like hepatocytes and adrenal cortical cells, are infected, and finally epithelial cells and fibroblasts. The infection can affect almost every organ in the body, and cause widespread cell death. Bleeding, when it occurs, is caused by disseminated intravascular coagulation (DIC), probably due to the activation of macrophages and the release of pro-inflammatory cytokines. There may be apoptosis of lymphocytes late in the disease course, causing further immuno-suppression. The case fatality rates for Ebola and Marburg infections have generally been reported as being between 50-90% in an African setting, depending on the strain of virus. Certain strains of Ebola Zaire have been shown to cause more severe infections than other strains. The chances of survival of individual patients are linked to the effectiveness of their immune response. Mild cases occur due to an effective immune response with little immuno-suppression. Recovery occurs after 10-14 days of illness and is associated with the appearance of effective anti-bodies. Although this variability of survival and of immune response between patients has been used to argue that survival may depend little on medical care, there is evidence that good supportive medical care improves outcome. The first outbreak of Marburg in Europe had a much lower case fatality rate than other epidemics of the same disease, probably due to the care given. It should be noted that in the final stages of the severe illness, the presence of fever may not be a reliable sign, and many patients with severe disease may be apyrexial. Therefore the presence of fever can not be used alone to guide diagnosis or discharge 2.7 Symptoms Symptoms tend to be non-specific and similar to those of common tropical diseases (notably malaria, shigellosis, typhoid fever). This makes a clinical diagnosis very difficult, especially outside of an outbreak situation. 2.7.1 Ebola Symptoms can include: Sudden onset of high fever. General weakness. Muscle pain. Headache. Sore throat. Hiccups. Followed by Vomiting (bloody). 25 Diarrhoea. Rash. Chest pain. Reduction of kidney and liver functions (results of the severity of the disease and reflects the presence of multi-organ failure). Internal and external bleeding. The patient then often goes into shock and eventually dies. 2.7.2 Marburg Symptoms can include: Severe headache and malaise High fever. Muscle pain Watery diarrhoea, abdominal pain, nausea, and vomiting Non-itchy rash Internal and external bleeding. Confusion, irritability, and aggression Orchitis (inflammation of the testicles) The patient then often suffers severe blood loss, goes into shock, and eventually dies. 2.8 Incubation Period Ebola 2-21 days. Most common period 7-14 days Marburg 3-9 days. Most common period 4-5 days 2.9 Laboratory Tests The initial clinical diagnosis of these diseases based on symptoms alone can be difficult. Laboratory confirmation is important, and confirmation is required before an outbreak is declared. Samples are normally sent to internationally recognised reference laboratories with the necessary bio-security facilities. Due to the time required for the transport of samples, test procedures, and the communication of results, it can take a number of days before an outbreak is confirmed. Caution dictates that reinforcement of Standard Precautions and specific VHF precautions must be implemented while awaiting laboratory results. The most important approaches to testing for infection are the measurement of the hostspecific immune response, and the detection of viral particles or particle components. Currently used laboratory tests and techniques for detection of the viruses are: Antigen Capture ELISA (Antigen-capture enzyme-linked immunosorbent serologic assay): detection and measurement of Ag, IgG & IgM antibodies. RT-PCR (Reverse transcript Polymerase chain reaction): detection of genetic material (RNA). Immunohistochemistry: detection of viral antigen (skin snip). Virus isolation (culture). Field-based real-time testing is now possible with techniques and portable equipment developed by the Health Canada - National Microbiology Laboratory. With this method test results can be produced in 4 hours; this is invaluable for the management of suspect cases in an outbreak situation. 26 However, laboratory tests are constantly being refined and this list may be modified in future epidemics as new information becomes available on the benefits and limitations of each test. The testing methods should be discussed directly with the laboratory in question, as not all the tests are reliable at all stages of the disease. For further information, see Laboratory Diagnosis of Ebola and Marburg Haemorrhagic Fever 28_06_05.pdf on the CD. See Annex 2 Sample Collection and Transportation. 2.10 Previous Known Outbreaks From the figures in the tables below, it can be seen that in terms of public health importance, Ebola and Marburg outbreaks are of limited significance when compared to malaria or diarrhoeal disease. However, an outbreak can spread quickly in a community and causes great suffering and distress; moreover, the infection rate of health staff can be severe, resulting in the death of many health workers. Hence, the major objectives are to prevent spread in the affected community and to protect the health workers working in the isolation units, and in other hospital services. Table 1 - Ebola Outbreaks Year Country 1976 1976 1977 1979 1994 1994 1995 Sudan Zaire (DRC) Zaire (DRC) Sudan Gabon Côte d’Ivoire Liberia Democratic Republic of Congo Gabon 1995 1996 (Jan - Apr) 1996/1997 (Jul Jan) 1996 2000 - 2001 2001/2002 (Oct Mar) 2001/2002 (Oct Mar) 2002/2003 (Dec Apr) 2003 (Nov - Dec) 2004 (?-?) Ebola virus subtype Ebo-Sudan Ebo-Zaire Ebo-Zaire Ebo-Sudan Ebo-Zaire Ebo-Côte d’Ivoire Ebo-Côte d’Ivoire Ebo-Zaire Ebo-Zaire Gabon Ebo-Zaire South Africa Uganda Ebo-Zaire Ebo-Sudan Gabon Ebo-Zaire Republic of Congo Ebo-Zaire Republic of Congo Ebo-Zaire Republic of Congo Sudan Ebo-Zaire Ebo-Sudan Totals Cases Deaths 284 318 1 34 52 1 1 315 151 280 1 22 31 0 0 250 Case fatality 53% 88% 100% 65% 60% 0% 0% 81% 37 60 21 45 57% 74% 1 425 65 1 224 53 100% 53% 82% 59 44 75% 143 128 89% 35 17 1848 29 7 1287 83% 41% Cases Deaths 32 3 2 1 154 374 566 7 1 1 1 128 329 467 Case fatality 21% 33% 50% 100% 83% 88% Table 2 - Marburg Outbreaks Year(s) 1967 1975 1980 1987 1998 - 2000 2004 – 2005 (?-?) Country Germany and Yugoslavia South Africa Kenya Kenya Democratic Republic of Congo (DRC) Angola Totals 27 2.11 MSF Experience MSF has been involved in most of the recent outbreaks of Ebola, and the last two major outbreaks of Marburg. MSF’s activities have focused primarily on case management, isolation, and infection control; in recent outbreaks, activities have expanded to include community oriented and psychosocial activities, epidemiological and surveillance followup, and organisation of burial and ambulance services. 2.12 Filovirus Outbreaks as a Global Social Phenomenon In popular culture, Marburg and especially Ebola have a particular notoriety. Books and films based loosely on fact promote the idea that these diseases are liable to infect the whole world if an outbreak occurs or following an accidental release of the virus. The recent international focus on terrorism brought Ebola and Marburg back into the news, not as terrible diseases that affect some of the world’s poorest people, but as potential new tools in the terrorists’ arsenal. All of this contributes to the fear and paranoia throughout the world; this over-dramatised fear and paranoia reaches villages and communities in remote parts of Africa. The popular perception of the disease coupled with fear, rumour, and a lack of information can result in communities losing confidence in the health system and services, and can make outbreak control activities very difficult. If the communities have reached a point where they do not have trust in the health services and the information and messages being disseminated, it can be very difficult to regain their trust. This is why the early implementation of health promotion and social mobilisation activities is particularly important, and every opportunity should be taken to provide rational, accurate explanations about the diseases and the risks. Community perceptions should also be taken into account when planning and designing activities in the intervention. Back to Table of Contents 28 3 Outbreak Management This section provides an overview of the management and coordination issues. It explains the need for coordination and integration of the intervention components, and the need for good coordination between the different actors. Primary audience: Coordinators. Secondary audience: All persons involved in outbreak control activities. 3.1 Introduction The general approach to controlling an outbreak comprises three main components: Epidemiological-surveillance system. It is important to have an epidemiological overview of the size and evolution of the epidemic. This information will help in identifying transmission lines and coordinating where and how to stop the spread of infection. Information, education, and sensitisation. It is imperative that affected communities, health staff, and others are informed as soon as possible about the disease, the symptoms, the modes of transmission, and the measures taken to control the outbreak. They must also know how to protect themselves, and what to do if they suspect that they may have contracted the disease. Case management, containment and isolation Suspect and probable/confirmed cases must be cared for in a safe and dignified manner. Proper isolation of patients reduces the risk of transmission in the community and allows the provision of patient care in a safe environment. The approach taken, and the division of responsibility to implement these component activities will depend on the size of the outbreak, the location (urban or rural environment), the standard of existing health facilities and infrastructure, and the presence of other operational actors in the field. In most cases, MSF will be an operational partner, sharing responsibility for the different components with the Ministry of Health, WHO, CDC, Epicentre, etc. In the case of a small outbreak where the presence of other actors is limited, MSF could take responsibility for the overall coordination and management of all outbreak activities in collaboration with the Ministry of Health. It is extremely important that all outbreak control activities are coordinated, and implemented at the right time and in a correct manner. If there is a delay or failure of one activity then this can have a serious negative impact on other activities, and potentially the success of the entire intervention. It is essential to observe and monitor all activities to ensure that they are implemented in a decent way. If this is not the case then it may be necessary to suspend certain activities until all are at the same speed, or to reallocate responsibilities for activities. 3.2 Key Actors Involved in Outbreak Response Other actors can include WHO, Epicentre, CDC-Atlanta, Health Canada - National Microbiology Laboratory, Red Cross, Pasteur Institute, and various academic institutions. 29 WHO will almost certainly be present in an outbreak, and more often than not will take charge of the overall coordination in collaboration with the National Authorities. The presence of other actors will depend on the location and scale of the outbreak. See Annex 16 Main Intervening Organisations in VHF Outbreaks for contact details. 3.3 The Importance of Coordination & Integration of All Elements It is essential that all elements of the intervention are integrated and coordinated. Information flow must be coordinated and made systematic between the different activities. Below is a schematic showing the communication and information flow necessary to admit a patient to an isolation unit following the report of a rumour in the community. Figure 1 - Admission: Communication & Information Flow Case Finding Rumour of Case Alert Team Epidemiological Base Contact Tracing Ambulance Team Mobile Team Coordination Treatment Unit Triage Laboratory Treatment Unit As can be seen there are numerous people, teams, and activities involved in the process, and good coordination and communication between them is essential to avoid problems. Analysis of prevailing social and cultural factors that could affect the intervention is very important. A good understanding of these issues is helpful for the following: Designing and planning appropriate health promotion and social mobilisation activities that are acceptable to the community. Adjusting procedures and the design of the isolation unit to improve acceptance by the community. Adapting ambulance, household disinfection, and burial procedures to improve acceptance. Back to Table of Contents 30 4 Epidemiology This section deals with the epidemiological and surveillance activities that are necessary in an Ebola or Marburg outbreak. It explains what is required, why it is necessary, and how to go about organising the different activities. Primary audience: epidemiologists, persons implementing surveillance activities. Secondary audience: outbreak coordinators, clinicians. 4.1 Introduction In most cases WHO will be present in a VHF outbreak. Epicentre, CDC, and Health Canada National Microbiology Laboratory may also be involved. There is often a significant amount of overlap of responsibilities and activities between the different organisations. WHO are likely to take overall charge of the outbreak coordination and of surveillance activities. MSF take charge of the collection, management, and analysis of epidemiological data. Epicentre can provide epidemiological support for outbreak investigation activities involving collection, management, and analysis of epidemiological data. CDC and Health Canada may provide laboratory facilities and contribute towards the collection of epidemiological information. It is important that MSF coordinate closely with the epidemiological team(s) collaborating with surveillance, the collection of data and analysis. These activities must be monitored to ensure that they are done appropriately and in a timely manner. 4.2 Principles of the Epidemiological Response To implement a reliable surveillance system to detect cases of Ebola or Marburg. To track the evolution of the epidemic, with analysis to support its management and containment in coordination with partners. To gather and analyse data which can aid in the description of the disease characteristics. To provide feedback to relevant authorities. Specific Components Detection: Providing a framework to ensure sustainable surveillance up to the declared end of the outbreak and integration of post-outbreak surveillance into routine surveillance activities. Establishing a community level surveillance system to detect cases (using case definitions) and monitor mortality through mobile teams. Identifying all cases and contacts and ensuring reliable contact tracing activities. Description Collecting reliable data on patient demographics (age, sex, and location), symptoms, treatment, case confirmation status, and clinical outcome. Analysis: Ensuring collection, management, and analysis of data related to all (suspect, probable and confirmed) cases with specific attention to patients admitted in an MSF treatment programme and any infected health staff. Providing an epidemiological description of the epidemic in terms of time, place, and person. 31 Providing regular information on the evolution of the outbreak and interventions to health authorities (MOH), WHO, the national and international community and media about the number of cases, deaths, admissions, etc. Identifying possible epidemiological links between cases (confirmed and probable), and determining the main modes of transmission. Providing technical advice with regard to the MSF intervention, and ascertaining whether control measures are effective. 4.3 Surveillance Activities Case Definitions Case definitions are used to identify suspect cases and to isolate them as early as possible. They are a critical component of outbreak control and surveillance activities. Case definitions should meet the following criteria: They should be simple, and straightforward to understand and apply. All partners involved should agree upon the criteria and definitions as early as possible. The case definitions should be revised and revalidated after 2 to 3 weeks of data collection and analysis, to ensure that they remain relevant and appropriate in light of the available clinical and epidemiological data of the ongoing outbreak. (This should result in the case definitions being more specific, i.e. fewer false positive cases will be included and subsequently isolated.) Changing the case definitions can have an important impact on the data collected and their interpretation. Any change should therefore clearly be noted when presenting and interpreting the data. It is useful to have different levels of case definitions, e.g. alert case, suspect case and probable case definitions. The specificity and the sensitivity are related to the level of the case definition used. The alert case definition is more sensitive than the suspect, and the suspect more sensitive than the probable. The reason for using different levels is to include all possible cases at the alert stage (high sensitivity), and then to include only the more likely cases at the suspect and probable stages (higher specificity). Alert Case Definition: Used to decide whether someone in the community should be further evaluated. Applied by community members. Action if positive is to summon the mobile team. Suspect Case Definition: Used to decide whether someone who is ill (such as an alert case) needs to be isolated. Applied by the mobile team or other health professionals and subsequently confirmed by the physician in charge of the isolation ward. Action if positive is to (a) isolate the patient; (b) start contact tracing and follow-up activities. Confirmed Case Definition: Used to decide definitively whether a patient has the disease. isolated suspects. Applied by physician in charge of the isolation ward. Usually applied to 32 Action if positive is to move the patient into confirmed area of isolation ward, and to start contact tracing and follow-up activities (if not already started as a suspect case). Action if negative is to discharge from isolation (confirming the negative result if there is clinical doubt). Probable Case Definition: Usually used retrospectively by epidemiologists to classify patients that likely had the disease but where confirmation is impossible (e.g., patient buried without testing). In settings where a laboratory is not present (or results are delayed or of unclear validity) it may be used in patient management to stratify risk. Action if positive would be to separate the isolated patient from other isolated suspects who do not meet the probable definition, and to start contact tracing and follow-up activities (if not already started as a suspect case). Examples of Case Definitions Marburg (Uige 2005) This case definition was revised 6 Ebola (Gulu 2000) weeks after the start of the intervention Alert case Any case of sudden onset of high fever OR Sudden death OR Bleeding or bloody diarrhoea or blood in urine Any case of sudden onset of high fever OR Sudden death OR Bleeding or bloody diarrhoea or blood in urine (Notify by community member) Suspect case Any patient with unexplained haemorrhage OR fever (except post-partum or antipyretic treatment) + 3 or more of the following symptoms: Headache Vomiting Anorexia Nausea Fatigue Diarrhoea Myalgia Dysphagia Arthralgia Hiccup Dyspnoea (Notify local health centre or mobile team) Probable case Confirmed case All patients with any of the following signs, even if PCR analysis from gingival swab was negative 1 and no blood sample available): Fever + haemorrhage Death + epidemiological link* Two symptoms + epidemiological link* Any patient with a positive laboratory result: PCR (gingival swab or blood), serology, or virus isolation. * Epidemiological link: Contact with probable or confirmed case Contact with sick or dead animal Treatment (transfusions, injections, scarification etc.) at health centres or with traditional healers (Notify local health centre or mobile team) All persons, living or deceased, with fever + contact* with a case of Ebola OR fever + 3 or more of the following symptoms: Headache Myalgia Vomiting Dysphagia Anorexia Arthralgia Nausea Hiccup Weakness or Dyspnoea severe fatigue Abdominal Diarrhoea pain OR Unexplained bleeding of any kind. OR Any unexplained death; complete forms and notify burial team. (Refer to hospital) Laboratory present, therefore not used. Any patient with either Ebola virus antigen, or Ebola virus antibody (IgG) detected in blood samples. * A contact is any person who comes into contact with a case by: Sleeping in the same household within 1 month. Having direct physical contact with a case 1 At the time of this outbreak, the oral swab was still to be validated as a test. Sensitivity seemed to depend on the progress of the disease. Therefore, in case of negative test results, the clinical evaluation of the medical doctor was considered dominant. 33 (dead or alive). Having contact with materials or body fluids. contaminated Note: Other risk factors include burial attendance, hospital admission, injection, or vaccination in previous 21days. Possible indicator: Spontaneous abortion. Case Detection Considering the infectivity, high case-fatality rate, and the stigma and fear associated with these diseases, a proactive approach to the identification of new cases is extremely important. Early detection of new cases is vital and allows for early isolation and/or implementation of nursing barriers in order to limit new chains of transmission, and to contain the epidemic. This proactive approach can demand major inputs of time, and human resources especially in large and geographically dispersed outbreaks. Nevertheless, early detection of cases will have a significant impact on the control and containment of the epidemic. Furthermore, the presence and interaction of the case detection teams in the community can help to build a trusting relationship with the affected population; in order to achieve this, the teams must be trained to work in a sensitive and diplomatic manner that facilitates developing good relations with the communities. Case detection can be conducted actively and/or passively, as follows: Active Case Finding 1. Alert Reporting System carried out by community alert teams (see description below). These community teams trained in the use of the alert case definition can help to build a trusting relationship with the affected population 2. Active Case Finding carried out by mobile surveillance teams who are also in charge of the contact tracing (see description below). Case finding can be done when visiting the families of cases, meeting with the community leaders, and by visiting the health facilities to enquire about any suspicion or alert of case. Passive Case Finding 1. Spontaneous Alert Reporting by family or community members who report that there is an alert case directly to the community alert teams, the mobile teams or other health personnel. 2. Identification of cases within the triage system of the health structure (see description below). Relying solely on passive case finding methods may not be very effective as they rely on the follow-up and investigation of new suspect cases that are reported by community members, or identified within the triage system of the health structure. Depending on particular constraints in an outbreak, this may be the only feasible approach. However, to be even moderately successful, passive case finding requires that the community has confidence in the intervention and the health structure, and that the triage system is working properly. Contact Tracing Tracing and monitoring people who have had contact with suspect and probable cases is a proactive and valuable strategy for the identification of new cases. It is an extensive and laborious intervention, it must be implemented in a rigorous and systematic manner, and it must be supervised actively and carefully. However, it is one of the few ways to ensure a proactive response to the outbreak, therefore it is important to ensure it is done, and done correctly. 34 Key points are: Fill out a contact tracing form for each case. See Annex 12.6 Contact Tracing Form. Follow up all contacts of cases for 21 days. Allocate sufficient time to see and assess each contact individually. If this is difficult to arrange during normal working hours due to their other commitments, an agreement with the family can be made on appropriate times to visit, alternatively the particular person can be assessed every 2nd day. The first meeting with a contact and their family will require extra time to discuss and explain why the contact tracing is being done, that it is in their interest, and to gain their cooperation and consent to the daily visits. Each contact tracing team should have at least one medically trained person (ideally a doctor or nurse), to evaluate and put in perspective the sometimes atypical, but indicative, complaints and symptoms. While this person focuses on the medical part, a second (non-medical) person could be in charge of the awareness raising and social issues. One of the roles of the contact tracing teams is, through their daily presence, to gain the trust of the community. Train teams to take time with the families and to have a patient and open attitude towards them. Due to logistical or staffing constraints, it may not be possible to visit every contact every day. If necessary, a more targeted contact tracing approach can be established. Through the in-depth interviews with the families of probable and confirmed cases, identify persons who have had the most risky types of contact i.e. direct contact with the patient, their body fluids, or contaminated material. These people will be at a higher risk of infection, and can be targeted for more frequent follow-up. Monitoring of Burial Team Activities Information on the activities of the burial teams must be collected. The data on the burial activities can be very useful as they provide information on the daily workload of the teams and on the proportion of Ebola or Marburg patients for whom verified safe burial practices were used. In addition, these data permit crosschecking of mortality surveillance data. This information can also help to understand the situation in the communities in terms of mortality related to VHF, especially if admissions in the isolation unit are low and there are many suspect cases dying in the community. Apart from the basic identification data (name, age, sex of the deceased, and place of origin), the lab test result should be noted, together with details of who carried out the burial, and whether disinfection of the patient's house was done. A daily follow-up of these data should be done in order to monitor the situation, and to ensure that burials and house disinfections are being done promptly. Data to collect Name, age, and sex of the person buried. Place of origin, community. Date of onset of illness (if known). Final case status: suspect, probable or confirmed. Date of death. Date of burial and details of burial team. 35 Whether house disinfection done or not. Contact history and contact tracing list. Mortality Monitoring in the Health Facility Monitoring should take account of the aetiology, and this approach can function as an alert mechanism. All deaths occurring in the health facility should be monitored and evaluated to identify any that are VHF related. This is useful to assist in identifying shortcomings in the triage system, the implementation of standard precautions, and infection control. Surveillance of Regular Medical Activities In outbreaks where health facilities have played a major role in propagating the epidemic and many patients and health workers have been infected, the impact on public health can be serious with decreased confidence in the medical system and reduced attendance in the medical structures. The population may be too afraid of using the health facilities, as they are focus points of infection. Because of this, sick people may stay at home with no medical care, or they may choose to use informal or traditional therapies. This can result in elevated mortality related to VHF or other pathologies, A weekly surveillance of the hospital and health facilities activities should be conducted and the level of attendance before and during the epidemic should be compared. This information can indicate problems in access to health care for non-VHF patients. Monitoring of invasive medical acts in the health facilities is particularly important as this can indicate areas requiring further attention and improvements of infection control. Surveillance of Medical Personnel The epidemiological description of the medical personnel involvement allows an evaluation of their risk exposure, and the setting of priorities for intervention for their protection. Considering the professional risk exposure, support to the staff and their families must be provided. By describing the medical personnel involvement, the risk for professional (nosocomial) infection at different hospital departments can be identified and documented. Local medical personnel are at the front line of the epidemic response. Infection control activities and the protection of the medical staff must be a priority from the start of an intervention. Provide proper protection material; begin training on its proper use and on infection control as early as possible. The infection control and barrier nursing practices should be supervised closely and continuously for the whole duration of the intervention. Adequate support and protection of the health personnel will increase their confidence and motivation to continue to work in the extreme conditions of an outbreak of haemorrhagic fever. Psychological, moral, and material support to the families of involved medical staff must be provided. The families of medical staff, who die because of the epidemic, should be given particular psychological and moral support; the professional risk and the commitment of their relatives must be recognised, this may help them in the difficult mourning process. Practical Organisation of Surveillance Activities The surveillance activities imply collecting personal and sensitive information about large numbers of community members. It is imperative that patient confidentiality is maintained 36 at all times. The concept and importance of patient confidentiality must be stressed when training people to implement surveillance activities. Community Alert System Identify and train a network of people in the community to: Recognise alert cases using the Alert Case Definition. Reassure the family of the alert case and inform them about the next steps. Report alert cases to mobile surveillance teams or local health care units. Educate and inform the community. Care is necessary in selecting people for the community alert system; they must be responsible and discrete. Peripheral Health Care Unit Alert System Train peripheral health care workers to: Put in place or reinforce standard precautions. Triage patients and evaluate whether a patient is a suspect case. Monitor the clinical evolution of inpatients and identify those who develop suspicious VHF symptoms. Report the case to a mobile surveillance team or to the operations centre. Safely accommodate the case until a mobile team or ambulance team arrives (if health-centre with in-patient facilities). Inform and educate the community on VHF prevention. Mobile Surveillance Teams Train and equip mobile surveillance teams to do: Active case finding. Contact tracing & follow-up. Mortality surveys (if appropriate). The number of teams will depend on the size and spread of the outbreak. For example, in Gulu (Uganda 2000), there were 32 teams with a total of 128 persons carrying out the surveillance activities. Mobile teams travelling to distant locations, must be equipped with transport and communication material. 4.4 Data Management Organise and classify data by person (age), by time and by place. 1. Data on the age of cases and deaths is important to collect. If it is difficult to acquire accurate age information, data should be organised by age group: <5 years and >5 years. 2. The time data, including date of onset of illness and date of death, allows the preparation of a graph describing the number of cases and deaths per day to illustrate the evolution and amplitude of the epidemic over time. 3. Data on the geographic distribution of cases by neighbourhood, village, and district can be used to identify and map areas at greater risk, and to monitor outbreak expansion. Patient Data (suspect, probable and confirmed cases) Knowledge of Ebola and Marburg is quite poor. Good data collection allows the possibility for further analysis and research after the outbreak, which can contribute to improved responses in future outbreaks. A prospective ethical review of such research should be done to ensure that the collection, management, and analysis of the data conforms to 37 ethical norms, confidentiality is respected, and findings are valid. Data collection and analysis for this purpose should focus on operational aspects, i.e. treatments, symptoms, outcomes, etc. The Epidemiological Form administered for each patient should not be too detailed or laborious to complete, nevertheless essential information on clinical presentation, development of symptoms, contact history, and exposure to possible risk factors must be collected: Clinical assessment: date of onset of symptoms; presence and duration of main symptoms; presence of other (secondary) symptoms. Lab investigation: type of sample taken; date, and number of days after onset of symptoms that sample was taken; and lab result. Contact with suspected VHF patient: name and address; date of last contact; type of contact. Exposure to possible risk factors o Presence at burial: date, direct contact with corpse? o Previous treatment: oral, injection, enema, etc. o Traditional medicine: scarification, injection, enema, etc. Isolation Ward and Home Based Support and Risk Reduction A standardised epidemiological form, administered systematically for each suspect, probable and confirmed patient ensures a uniform documentation of the characteristics of the outbreak and its magnitude. Essential information on clinical presentation, contact history, and exposure to possible risk factors must be collected. See Annex 12.8 Epidemiological Form. The Epidemiological Form contains similar information to the Medical Admission Form. Information can be transferred from one to the other to avoid asking the same questions repeatedly. One person should be responsible to ensure that the forms are completed for every new admission to the isolation unit or to the Home Based Support and Risk Reduction programme. The Observation Sheets filled by medical staff in the treatment ward contains important data on the evolution of the individual cases. This clinical data detailing the development of symptoms is extremely valuable for furthering the understanding of the disease. Data from the observation sheets should be transferred to the epidemiological databases. See Annex 12.3 Observation Sheet. It is also necessary to collect data for the statistics of the functioning of the VHF treatment ward: admissions, discharges, deaths, recoveries, referrals, runaways. See VHF Ward Statistics spreadsheet on the CD. Other Areas Train alert investigation teams to fill in the case report form for every investigated case, and submit the forms to the person responsible for the database. Monitor this closely to ensure that all cases and patients are included in the database. The physicians working in the hospital wards must complete case report forms for all patients considered suspect. The Epidemiological Forms of all (suspect, probable and confirmed) patients should be centralised in one database, which will most likely be managed by the Ministry of Health in collaboration with WHO. 38 Update the graph describing case numbers and deaths on a daily or weekly basis. This allows the evolution and trend of the ongoing epidemic to be observed. Keep all records; none should be deleted, even if a patient is discarded as a case. In order to ensure the integrity of the database and to avoid problems, daily communication between the different partners involved in data collection, and/or an epidemiology meeting should be organised. All new patients to be entered (alert investigations, admissions at the isolation ward, admissions in the home-based care programme, etc.) should be reviewed and crosschecked against the laboratory records. Problems can occur with transferring data and information out of the VHF ward. Data and information recorded on paper sheets can not be taken out of the ward, as they are difficult, if not impossible, to disinfect reliably. The simplest methods to overcome this are to dictate the information “over the fence”, or to attach the data sheets to a board that can be read from outside the ward so that the information can be transcribed. This transfer of information should be done at least once per day. Care must be taken to maintain patient confidentiality. In a large ward with many patients, these methods can be laborious and very timeconsuming. Where large amounts of information must be transferred, consider installing a basic laptop or PDA with a mobile modem card or a data-link cable connected to a computer outside the ward for transferring the data. This would greatly simplify and speed the transfer of information, and the cost of a “throwaway” laptop relative to the total cost of the intervention is small. The laptop must be sensibly located and be well protected from chlorine solutions. At the time of writing, a new relational database programme developed by WHO is being field-tested. FIMS (field-information-management-system) shows promise as a customisable and adaptable database tool for collection and analysis of epidemiological information. Check progress of field-testing, and availability of this programme with headquarters. Rumours and Alert Case Data In order to centralise and follow up on informal reports of cases, establish a “rumour and alert registry” to systematically record information on these rumours and alerts of cases in the community. Key Elements A well-defined person(s) at a well-defined and easily accessible place to manage the register. The service should be available 24 hours a day. There must be easy and direct contact with both the local community and the investigation and control teams. Register must be carefully maintained, and used to provide information for the investigation teams. Its existence must be widely advertised in the community. A telephone “hotline” should be set up if telephone services are available. Case Interviews and Identification of Epidemiological Links In-depth interviews with probable, confirmed, and convalescent patients and their families, and with the relatives of deceased patients, allow for a better understanding of the dynamics of the epidemic. They also allow for the identification of epidemiological links 39 between confirmed, probable, and suspect cases. Establish an adapted database for the analysis of this information. Use the Epidemiological Form as a starting point for the interview and discussions. These interviews are one of the few entry points for direct contact with the families of VHF patients, and they allow a good opportunity for communication and discussion. Families will be scared, anxious, and bewildered, and they are likely to use the occasion to express their anger and fears. Ideally, the interviews are done at the home of the family, in the presence of all persons who have been in close contact with the patient. The discussion should be open, without forcing the persons to talk. Use a checklist to ensure all necessary aspects are covered. If possible, traditional leaders should be involved in the organisation of these interviews. These interviews can allow the identification of important links between several patients, as well as the identification of new patients and the close follow-up of persons at higher risk. It is highly likely that some patients (often the milder cases) would not be identified without this exercise. The in-depth interviews should be carried out systematically for all confirmed, probable, and suspect cases. They should not be delayed once a patient is identified as a case, since they can allow more targeted contact tracing as well as facilitating early case detection. Below is an example from the Marburg outbreak in Uige in 2005, showing the epidemiological links involving four families living very closely together. Figure 2 - Epidemiological Links (double click in box for animation or follow link Epidemiological Links) The primary case is Christina, who had severe haemorrhage following delivery. She was admitted to the Cristina, F, 37y isolation ward and tested positive for S: 11/04 Marburg. After her death, her D: 13/04 Miguel, M, 7w husband fled, leaving the newborn Baby, F, 2w S: 30/04 baby with the Christina’s niece, D: 22/04 D: 3/05 Marquinha, and with Isabel, both neighbours, who both shared the breastfeeding of the newborn. The Marcelina, F, 40y Marquinha, F, 18y baby died 10 days later. Another 10 S: +/-17/04 - Cured S: +/-29/04 days later, both Marquinha and D: 2/05 Isabel died. Their own babies, who Luis, M, 19y they were also breastfeeding, were Asymptomatic Juliana, F, 16y infected and died. Marburg virus was S : 29/04 Videira, M, 5m isolated from Marquinha’s breast D: 1/05 S: 5/05 milk. It is unclear what the exposure was for Marquinha’s husband; as D: 8/05 S = Date of onset of Gomez, M, 5y soon as Marquinha fell sick she was symptoms S: 26/04 - Cured D = Date of death left alone with her baby in a separate house until she died. Another close neighbour, Marcelina, visited Cristina in her home after the delivery. She started symptoms about 1 week later. She lived together with her daughter Juliana, who was a very close friend of Marquinha, helping her out with the care of the children and the household. Juliana died the day before Marquinha. Marcelina has a second child, Gomez, a 5-year old boy who became sick about 10 days after her. Both Marcelina and Gomez were discharged from the isolation - recovered - on the 8th of May. Chico, M - fled Isabel, F, 32y D: 1/05 40 Epidemiology Information Flow A clear flow of information needs to be established in order to avoid incomplete records or double case counting, and to ensure that information is shared appropriately and in a timely manner. As the figure below illustrates, the flow of epidemiological information can be quite complex. Figure 3 - Epidemiology Information Flow Ambulance Teams Burial Teams Mobile Team Coordination Disinfection Activities Mortality Surveillance Epidemiology Base Rumour Control Triage & Peripheral Health Structures ! Triage & Hospital Wards Contact Tracing Teams Case Finding Teams Laboratory Isolation Unit At the outset, particular attention is necessary to ensure that the surveillance system is well designed and functioning smoothly. Otherwise, difficulties in updating databases and analysing information can arise. Common causes of these difficulties can be: A weak case definition. Problems with data quality. The complex flow of information. The multiple sources and routes of information. The absence of a common identifier allocated at the time of identification of a case (e.g. Name, Date, and Location). The collection of the same information by different persons using different collection methods. Mortality Surveillance Mortality surveillance is a technique that allows for a parallel monitoring of the outbreak. It can provide some basic information on the evolution of the outbreak, especially when cases are hidden by their relatives, and in a context of stigmatisation and limited confidence. Active surveillance of the total daily number of deaths during a VHF outbreak, not just those specifically due to VHF, can be useful as a proxy indicator of the epidemic evolution, and may assist in prioritising intervention activities. Active mortality surveillance will not always be necessary. However, it is useful when reliable death registers are not available, and if there is a suspicion that deaths are not 41 being reported. Otherwise, efforts and resources may be better directed towards contact tracing and case finding, and recording of disease manifestations and treatment modalities. While often not possible to make a distinction between the causes of death (i.e. VHF versus non-VHF deaths), mortality surveillance gives an indication of the trend of overall mortality. It makes a broad assumption that the rate of non-VHF mortality remains stable for the duration of the epidemic. However, when interpreting the data, effects due to the disruption to the functioning of health services and health seeking behaviours must be considered. General Mortality Data should be collected for each community on a daily basis. Identify and use the existing official death registration system (if any) as the source of mortality data. Where there is no death registration system or it is incomplete or unreliable, count the fresh graves at the main cemeteries on a daily basis. If details are available, collect the following information: name, age, sex, and cause of death. If no details are available, simple observation should allow distinguishing between the number of children and the number of adults buried on a certain day. It is likely that some burials will not be done at the main cemeteries; there may be a tradition of burying family members at home, and where there is pressure on the communities to avoid risky practices associated with traditional funerals people may conduct burials in secret. Monitoring and acquiring details about these burials will be more difficult, but should be attempted in order to have as good a data set as possible. This data collection should start as early as possible; consider available retrospective data; and continue the surveillance for the duration of the epidemic. See Annex 15 Job Profiles and Task Descriptions – Data Collector for Mortality Surveillance. Back to Table of Contents 42 5 Set-up, Installation and Organisation of Isolation Facilities This section covers the principles of isolation, the different isolation options available, the concept of risk zones, and the process of setting up an isolation facility. It describes important considerations to take into account in the planning and design. Primary audience: WHS, socio-cultural and logistics staff. Secondary audience: Coordinators. 5.1 Isolation Principles The approach of isolating patients is employed where the repercussions of contracting a particular disease are particularly serious, and/or where there is a high risk of contracting a disease through normal patient care contact. Ebola and Marburg meet both these criteria. 5.1.1 Objectives The objectives of isolating patients are to: Stop the spread of the disease within, and beyond, the affected community. Protect health staff by reducing and managing exposure to contamination. Provide safe, appropriate accommodation for suspect, probable, and confirmed patients. Provide a safe environment for patient management, and for supportive care of patients. 5.1.2 Considerations The design and planning of the isolation facility must allow all activities to be performed in a simple, straightforward, and easy manner, with a clear and rational movement and circulation of people and materials. Reducing complexity, confusion, workload and general stress contribute greatly to creating and maintaining a safe working environment. Depending on the context, it may be wise to avoid using the phrase “isolation ward” or “isolation unit”. In some situations and cultures, the term “isolation” can have very negative connotations. To increase acceptance use a more neutral term, for example “VHF/Marburg/Ebola Ward/Unit/Facility” or perhaps a more positive term “VHF/Marburg/Ebola Treatment Ward/Unit/Facility. This can be justified if decent treatment is provided. Everybody involved in the running of a VHF Treatment Unit must have detailed knowledge of the rationale, procedures, flows, circuits, and rules of the unit. Everybody permitted to enter the Unit is obliged to implement all safety measures, systems, and procedures. Continuous monitoring is essential to verify the implementation of these measures, and that staff rigorously follow all safety procedures. All activities are closely interlinked, and the execution of one activity can have a significant impact on others. This makes good coordination and communication essential, especially between those managing the medical and non-medical activities. The care of patients is critical, good care must be provided to all patients, and their humanity and dignity must be respected at all times. The achievement of medical and patient care objectives and the necessary link with safety levels in an isolation facility can be illustrated as follows: 43 Figure 4 – Relationship between Types of Care & Safety Levels In principle, the above scheme makes logical sense, but it should be interpreted according to circumstances. For example, on arrival in an outbreak area, it is likely that infected patients will be accommodated in some form of isolation area. The existing isolation, infection control, and disinfection measures put in place may not be of the highest standard; but with training and protection of the necessary staff, this should not prevent the early delivery of patient care. With appropriate training, personal protective equipment and a basic provision of disinfection and waste disposal/storage arrangements it is perfectly feasible to enter safely, work safely, and then safely leave a contaminated area. As soon as these basic safety measures have been implemented, the treatment and care of patients can begin. Image 1 - Initial Undressing Area Yambio Furthermore, a more aggressive approach to patient care including oral and IV medication and rehydration should be considered at an earlier stage if patient numbers are low (<10), and safety is ensured. The safety and security of staff and patients lie primarily in attitude and good practice rather than physical infrastructure. However, a well-designed, appropriate isolation facility contributes greatly to easing the workload, simplifying procedures, and reducing the risk of accidents. 5.2 Isolation Options Previous experience has shown that a single VHF Treatment Unit is the most straightforward to manage. There can be advantages in installing the Treatment Unit 44 within an existing health structure; the population knows the health structure and they will be accustomed to going there when sick. Furthermore, overall risks are reduced as all patients and contaminated material are centralised in one place, and training and supervision of staff is more easily ensured. However, there may be circumstances that may require a different approach. The analysis of information collected through the social and cultural assessments will assist in determining appropriate isolation options. This is especially important where negative perceptions and poor acceptance by the community of the health structure and conventional isolation are critical issues. The information collected can also assist in developing strategies for increasing isolation acceptance within the community. 1. If an outbreak occurs in an area where it would be inappropriate 2 or physically impossible to install a VHF Treatment Unit at the health structure or where there is no established health structure, then a separate, independent Unit could be arranged. This will require more time and effort as all facilities and services will have to be organized and installed. A triage service will be required at the hospital, and an ambulance for patient transport to the Unit should be provided. 2. Where populations are dispersed and travel is difficult, a central, main Treatment Unit could be supported by one or more small Treatment Wards in appropriate locations. These could be “mini” VHF Treatment Wards, or they could be suspect wards where patients are accommodated until test results are known, and they are either discharged or transferred to the main VHF Treatment Unit. The approach of using “mini” VHF Treatment Wards would also be useful where rural populations have a negative perception of the urban centre(s), and are reluctant to travel to the town. 3. Another option is to support families to care for patients via a home-based support and risk reduction programme (HBSRR). HBSRR is a provisional solution when care in a treatment unit is not possible or not immediately acceptable; HBSRR should not be viewed as a first-line option. Nevertheless, this approach can be relevant where the community does not trust the health structures and services, and where the community rejects the notion of isolation. However, it can be difficult to organise and manage with large numbers of patients, and ensuring the provision of adequate supplies and human resources is crucial. Furthermore, the risks to the patients’ families and the population are high, and the level of supportive medical care that it is possible to provide to the patient is extremely low. a. Home Based Support & Risk Reduction Programme can provide a mechanism to build support for the VHF Treatment Unit, and to maintain contact with patients that may otherwise be lost to any care at all. b. If the patient or his/her relatives do not accept admission to the Treatment Unit, admission into the Home Based Support & Risk Reduction programme can be offered to them. Once under this programme, a less dramatic atmosphere and more trusting relationship can be developed with the patient and his/her relatives, and they should be continuously encouraged to accept referral to the Treatment Unit. See Chapter 8 on Home-based Support and Risk Reduction. 2 For example, recent deaths have tainted the reputation of the health structure to the point where it is unmarketable or totally rejected by the population. 45 5.3 Cultural, Social and Psychological Factors 5.3.1 Community Acceptance of the VHF Treatment Facilities It is essential that the community accept the VHF Treatment Unit in order for it to be effective. Empty Treatment Wards during the acute phase of an outbreak can be an indicator of the failure of the epidemic control system put in place. Patients and their relatives may be extremely reluctant to accept admission to the Treatment Unit. Due to the nature of the disease and the relatively low chance of survival, there is great fear of the disease, and people can be reluctant to acknowledge that they may be infected. Furthermore, the idea of dying alone in “unnatural” isolation surrounded by strangers is not easily accepted, also the possible stigmatisation of the patients and their families can be an issue. The publicly visible provision of good care and treatment from the very beginning of the outbreak will contribute to improving acceptance of the VHF Treatment Unit. In order to increase acceptance and consequently provide a good service to the patients, it is necessary to take account of relevant psychological, social, and cultural factors in the planning and management of the VHF Treatment Unit. Information campaigns (radio messages, pictures, leaflets, etc.) can be used to explain the outbreak control activities and particularly the functioning of the Unit to the communities. Provide more targeted information to the health staff, the patients and their relatives, and the national and local health authorities. It is essential that there is a clear understanding of the following: The activities of the different actors. The kind of medical care that is provided to the patients. The rationale for the installation of the VHF Treatment Unit and the purpose of the strict infection control rules. Even when MSF is not in charge of health promotion/social mobilisation, MSF should be involved in the design, development, and delivery of the information material concerning its activities. In order to demystify the VHF Treatment Unit, and the disease: Be transparent. Offer clear relevant information. Ease access. Increase knowledge. Provide good care to the patients. Clearly explain the procedures and activities of the Unit to the community. The planning and design of the Treatment Unit should be conceived to facilitate humane treatment and to providing decent living conditions for the patients. It must be set up in a way that: Reduces suffering. Reduces the trauma to patients and their families. Reduces fear . Facilitates understanding and acceptance. The methods of working and the functioning of the Unit should be modified according to suggestions made by the health staff, patients, and community key people. 46 5.3.2 Improving Community Acceptance of the VHF Treatment Facility Examples of what can be done to improve conditions for the patients and increase community acceptance include: Provide active symptomatic and supportive treatment to patients, and be seen to be providing good care. Use familiar or local materials and methods for the construction of the Unit, where appropriate. Ensure that the fence is low enough to see over, or that there are sufficient “windows”, e.g. transparent or mesh material, built into the fence surrounding the Unit so that the public can observe what is going on inside. Mesh Fencing Around Low-Risk Zone Patient Entrance Gate Utilising Plastic Mesh Ensure the set-up and running of the Unit is as similar as possible to the normal hospital service. Provide patients with pleasant wards; where possible, separate the dying and severely ill from patients who are less sick. Intimate spaces should be prepared for dying patients and their relatives. Provide different spaces for pregnant women; probable/confirmed women breastfeeding probable/confirmed children; suspect and probable/confirmed accompanied and unaccompanied children, recovering patients and patients in the early stages of the disease. Provide radios and night lighting, and easily disinfected toys for children (not toys that are shared or that encourage running around). In areas where mobile phones and services are cheap, consider providing phones in the wards and at a location outside the Unit to allow patients to communicate with their families. Phones can be sealed inside waterproof plastic bags to facilitate their disinfection after use. Invite and encourage community leaders and health authorities to visit the Unit; this can help to reduce negative rumours about the Treatment Facilities and the intervention. Consider carefully which people will be helpful in reassuring the public, and will ensure the privacy of the patients. 47 Provide regular and timely information to patients and family members, and ease access for family members to medical staff so they can receive updates on the patients’ progress. Medical staff must play an active role in this; the psychologists can also assist in providing this service. Provide safe access to the ward for family members. Families must have access to their sick relatives from the very beginning of the intervention. A resting area for families can be set up outside the Unit. The exit from the morgue should be separated and out of sight of the patients’ and relatives’ entrance. Make psychological support for the patients and families a standard component of the MSF intervention from the beginning of the intervention. Brief and inform the health staff working in other hospital services about the disease and the risks. If necessary, provide psychological support in order for them to accept and care for patients discharged from the Treatment Unit (recovered or tested negative). If time and the situation permits (i.e. before patients are admitted), an “open day” for the treatment unit could be organised where key people could be invited to visit and view the VHF Treatment Unit. There is a risk that relatives visiting patients in the VHF Treatment Unit may be incubating VHF. When they become ill, their infection could be attributed to their visit to the Unit, and MSF could be accused of allowing their infection to occur. Clearly this could have a very negative impact on the intervention, therefore it is essential that the principle to allow visits to the unit is supported by all relevant players in the field, especially the local authorities and WHO. 5.4 Health Structure-Based / Independent VHF Treatment Unit The Treatment Unit must be set-up so that it is simple and straightforward to manage: Provide sufficient space for all activities. Ensure all necessary equipment and installations are in place. Ensure logical and appropriate locations for equipment and installations. All safety measures, circuits, protocols, and procedures must be easy to understand and easy to implement correctly. o Implement and supervise all safety measures and protocols. Create a safe working environment created that facilitates the delivery of patient care. 5.5 Site Selection Considerations for VHF Treatment Unit Care and attention to the process of selecting a good site will ease the set-up of the Unit, and contribute to its good functioning. 5.5.1 Local Support Agreement and support from Local Leaders and the Local Authorities is a precondition for setting up and running a VHF Treatment Unit. Without their understanding and support, it is unlikely to be accepted by the community. 5.5.2 Location The Treatment Unit should be as close as possible to the focal point of the outbreak, as transport of patients and corpses increases the risk of spreading contamination and infection. 48 5.5.3 Availability of Staff Sufficient medical and non-medical staff must be available to treat the anticipated number of patients. See Section 14.4 Staffing Needs for a 10bed / 50bed Treatment Unit. 5.5.4 Availability of Water Large quantities of water are essential for cleaning, disinfection, and other purposes. Approximately 70l of water per day per staff member working in protective clothing is required. A reliable supply of water must be available or arranged. If no water supply system is available at the site, arrange water trucking, and install a storage and distribution system. 5.5.5 Control of Infectious Material The Treatment Unit should be located adjacent to, or inside, the compound of an existing health structure, and separated from other departments. If this is not possible, choose a site that can be fenced and isolated to prevent disturbance, and potential contamination of nearby dwellings and community activities. Minimum distance 10m from perimeter fence to neighbouring dwellings. All isolation related facilities and activities must be located inside the Treatment Unit. Buildings should have smooth, impervious, easily cleaned floors and walls. Permanent buildings are preferable to temporary structures (plastic sheeting, tents). An existing isolation ward in a hospital, e.g. a cholera isolation ward will probably meet the above criteria. 5.5.6 Sufficient Space Suspect, probable, and confirmed cases must be accommodated in separate areas or buildings to prevent cross infection. Single patient rooms are the ideal, although, in most settings, and especially in large outbreaks, this will not be possible. In undivided wards, place separation screens between beds. It is important that adequate space be allocated for the suspect case ward. o Ensure the ward is large enough to place dividing screens between beds and allow adequate spacing between patients to reduce the risk of transmission to non-VHF patients admitted as suspects. o If no VHF laboratory is available on-site, diagnosis is more difficult, and patients stay longer in the suspect ward, therefore a larger ward is required. In undivided wards ensure sufficient space (2m) between beds to allow staff to work unhindered, and to reduce the chance of cross-contamination. Plan, and anticipate space for possible expansion of the unit in case of enlargement of the scale of the outbreak, and to allow installation of supplementary facilities including delivery room, paediatric ward and recovery/convalescent area. 5.5.7 Rapid Set Up The Unit should be operational as soon as possible. It might be necessary to improve an existing facility, set up a temporary facility, or hold patients at home with home based support & risk reduction while setting up and installing the definitive Treatment Unit. Ideally, all construction, installation, and preparatory works for the definitive Unit should be finished before patients are admitted there, or transferred from a temporary facility. 49 5.5.8 Other Issues It is difficult to achieve a good set up of isolation facilities in an infected structure with patients accommodated inside. This should be avoided, as performing physical work in full protective gear is exhausting, extremely uncomfortable, and increases the risks for the workers. Setting up a tented treatment facility is possible, but due to the less than perfect cleaning and disinfection that will be possible this creates difficulties of maintaining good infection control. However, this can be considered if no appropriate building(s) are available. Tent Structures at Yambio Treatment Unit An open setting, for example in a camp, village, or compound, should be avoided, as organisation of supportive measures is difficult. Although, in a small outbreak in a rural area, fencing and converting a house into a treatment ward can be considered. In extreme situations, it may be necessary to establish a cordon sanitaire around the compound or village where a VHF patient has been identified. A more appropriate site can be found and set up in the mean time. 5.6 Risk Zones In order to simplify procedures, ease the work, and reduce risks inside the Treatment Unit, activities and facilities are separated in different zones according to their level of risk. There are three risk areas: “High-risk”, “Low-risk”, and “Outside the isolation unit”. There is not a “no-risk zone”! See Annex 4.5 Summary of Facilities in Different Risk Zones. 5.6.1 Principles of the Low-risk and High-risk Zones Locate facilities and activities in the appropriate risk zone. Physically separate High-risk and Low-risk zones from each other and from the outside using fencing and/or existing walls and structures. Only trained and authorised people may access the different risk zones. Sluices and changing areas installed at entrances/exits of risk zones allow disinfection and changing of clothes. 50 ! Consider space and layout to allow possible sub-division of high-risk zone for different categories of patients: confirmed, probable, suspect, unlikely, observation, convalescent, paediatric, etc. Figure 5 –High-risk Zone, Low-risk Zone, and Areas outside the Isolation Unit OUTSIDE ISOLATION UNIT LOW RISK ZONE OUTSIDE ISOLATION UNIT Facilities OTHER HIGH RISK AREAS Dressing areas. Laundry. Doctors’ room. Stores. HIGH RISK ZONE Persons Facilities Patient areas – suspect, Medical Staff. Sanitation and support staff. probable/confirmed. Waste Zone. VHF Morgue. Small stock of materials. Persons Inner Fence Outer Fence Patients. Medical Staff. Sanitation and support staff. Authorised visitors. Health facilities in the whole epidemic area. Laboratories. Operating theatres. Morgues. Patients’ houses and VHF patient transport. OUTSIDE ISOLATION UNIT Resting Area/Counselling Room for patients’ families. OUTSIDE ISOLATION UNIT Training Area/Room for Isolation Unit. 5.6.2 High-Risk Zone The HIGH-RISK zone is the area inside the Unit where patients are cared for, deceased patients’ bodies are prepared for burial, and contaminated waste is treated and disposed of. This zone is highly contaminated and everything present in this area is considered as being contaminated, this includes the buildings; all equipment, furniture and personal belongings; waste materials; forms and paperwork; the patients, and the staff (prior to disinfection and removal of PPE). Full protective clothing and scrupulous disinfection is necessary. Only patients, designated staff, and authorised visitors are allowed into this zone. Waste treatment must take place in the High-Risk zone only; all waste from the Low-Risk zone is transferred to the High-Risk zone for disposal. 5.6.3 Low-Risk Zone The Low-Risk zone is the area inside the Unit where supporting facilities and activities are located including dressing areas, doctors’ room, laundry area, and stores. In principle, no infectious material should be present, however there is a real potential for contamination to occur due to uncontrolled movement of contaminated people and material. In the situation where the treatment facility is a single room, the low-risk zone can be reduced to a basic sluice area. 5.6.4 Outside the VHF Treatment Unit No infectious material should be present outside the Unit. However, as it is an epidemic situation, infectious material, or infected persons can be anywhere. Furthermore, the Unit will normally be installed within a hospital compound where there is a general risk of nosocomial infection. Standard Precautions and Additional Precautions to reduce VHF in health care settings should be followed. 51 5.6.5 Other High-risk Areas Patients’ houses are obvious locations that should be considered as high-risk areas; when entering houses the use of personal protective equipment is necessary, and rigorous disinfection of contaminated areas is essential. All morgues, medical laboratories, operating theatres, health centres (including private), and traditional health services in the epidemic zone have a high risk for infection. Measures must be taken to reduce risks in these facilities; limitation of services to only lifesaving activities, temporary closure, training of staff, and provision of materials and equipment can be considered. At the minimum, laboratory and operating theatre services must be limited to life-saving procedures until safe working practice is guaranteed. 5.7 VHF Treatment Unit Planning & Layout See Annex 4 Site Assessments and Planning. 5.7.1 Facilities Required Inside a VHF Treatment Unit High-risk Zone Ward(s) or rooms for suspect patients. o Latrines and bathing facilities for suspect patients. o Small store of materials and equipment for suspect patient area. o Water point. o Shaded area at fence for patients and visitors. Ward(s) or rooms for confirmed/probable patients. o Latrines and bathing facilities for confirmed/probable patients. o Small store of materials and equipment for confirmed/probable patient area. o Water point. o Shaded area at fence for patients and visitors. Waste zone with burner and pit, sharps pit, organic waste pit (do not use existing incinerators or waste areas). Area for the preparation of chlorine solutions. Morgue. Facilities for caregivers if they are admitted. Space or spare building for possible supplementary facilities (paediatrics, delivery, recovery, etc). Low-risk Zone Laundry and drying area. Area for the preparation of chlorine solutions. Doctor’s room. Store room. Changing room to enter and exit Low-risk Zone (Changing Room 1). Changing room to enter and exit High-risk Zone (Changing Room 2). Outside the Compound Kitchen for patients. Lunchroom for staff. Latrine for staff. Patients’ psychosocial consultation room near to patient entrance. Staff psychological debriefing area. 52 5.7.2 Fencing & Limiting Movement Limit access to the Treatment Unit and limit movement within the Unit: Put a fence around the Treatment Unit with mesh fencing in parts to allow the community to see into the isolation area. Mesh window in Fence Station guards at the entrances to the Unit to control access. Put fences between the different risk zones to prevent uncontrolled movement between the zones. 5.7.3 Changing Rooms Dressing and undressing must be done according to the protocols to prevent exposure to infectious material, and to prevent infectious material being carried out of the isolation unit. Staff put on and take off their protective clothing in specific changing rooms/areas. Two changing rooms are necessary: 1. Changing room 1: located at the entrance to the low-risk zone to put on and take off basic protective clothing. 2. Changing room 2: located at the entrance to the high-risk zone to put on and take off the additional PPE required in the High-Risk zone. The changing rooms are set up so that: 1. No cross contamination can take place. a. Staff entering (clean) and staff leaving (potentially contaminated) should not interfere with each other. b. Contaminated material cannot contaminate ‘clean’ material. c. The entry path should be separated from the exit path to prevent cross contamination between “dirty” and ”clean” people. 2. Staff are aware that they are entering a zone with a different risk level. a. Route through the changing room is clear to staff. b. The border between different risk-zones is clearly indicated (e.g. red line or benches). 3. All protective clothing is available and easily accessible. 4. The changing room between the high-risk and low-risk zones should be large enough and adequately equipped to allow more than one person to disinfect and undress at the same time (with large staff numbers allow space for 4-6 people). 5. The changing rooms and sluices must have good drainage, and easy to clean floors. 6. The changing rooms should have mirrors and adequate lighting to check protective gear. 53 High-Risk Entry Equipment High Risk Exit Chlorine Containers and Drain 5.7.4 Staff Circuits and Material Circuits The Treatment Unit should be planned and set up to allow a clear and logical circulation of people and material, allowing all activities to be done in a simple, straightforward, and easy manner. This contributes greatly to achieving a safe working environment and effective infection control. The Unit should be built so that the circuit prevents staff and/or contaminated material passing from the probable/confirmed area to the suspect area. “Clean” and “dirty” circuits of people and materials must be strictly separated and controlled. Entrances, exits, and “corridors” must be arranged to allow a clear and easy circulation avoiding cross contamination. Contaminated material should not pass from the probable/confirmed cases area to suspected cases area. Staff should always pass from less contaminated areas to the more contaminated areas, i.e. start work in the suspect area, and then proceed to the probable/confirmed area. o Training of the staff in this respect is essential; monitoring and close supervision is necessary to maintain this system, especially in a busy ward with a large number of patients. Marking materials (or using different colours) according to the zone they belong to is useful, as long as everybody understands the system. Another approach is to make it physically difficult for the staff to go from one area to another; place the entrance to the High-risk zone adjacent to the suspect cases area and the exit close to the confirmed cases area, physically separate the areas, and install a “one-way” route between the two areas. 5.7.5 Important Considerations Install three separate entrances/exits for staff, patients, and dead bodies Water points should be installed in all areas (low-risk, high-risk suspect, high-risk probable/confirmed). 54 Large quantities of water and disinfection solutions are used in the Unit. Therefore, a sufficient number of soakaways of adequate size must be installed for the disposal of wastewater and disinfection solutions. Consider the slope of the terrain; contaminated water must be prevented from flowing out of the contaminated areas into “clean” areas. Check the prevailing winds, and if possible, locate the waste zone and burning site downwind of other facilities. In the rainy season, pathways between buildings should be organised if not existing: options are to lay gravel or to construct an elevated path with brick or similar non-slip material. It is important to ensure good ventilation to reduce heat and humidity, and to evacuate chlorine gas. There is a risk of droplet transmission of infectious agents, therefore, air conditioning should be avoided, and fans should be used at their lower speeds. Install mosquito screening on windows and consider Insecticide-Residual-Spraying to reduce flies, mosquitoes, etc. Fencing must prevent unauthorised entry to the treatment unit; it must also prevent wind-blown materials from exiting the unit. However, fences should be constructed so that people can see over them or through them (mesh fencing) in order to help dedramatise the VHF Treatment Facilities. Shaded areas should be prepared at the exterior fence where visitors and family members can meet and speak with ambulatory patients. The area should be double fenced with a 2m gap to maintain distance and separation between visitors and patients. Seating could also be arranged. It is advisable to build the suspect and confirmed areas in a way that enables patients to perceive that the two areas are different and separated; this can be achieved by using distinctive materials or colours for each area. Suspect patients may be reluctant to accept admission to the VHF Treatment Wards, as they may fear that they may become infected. Clear, visual differences between the different areas can assist in convincing them to enter and stay inside the suspect area until lab results are available or their health status evolves. In practice, the set up will be done according to the nature and possibilities of the site. See Annex 4.4 Examples of Layouts of Previous Isolation Facilities. 5.8 Installation of the VHF Treatment Unit Once the site is selected and the site planning is done, the construction and installation of the necessary facilities and equipment can start. The amount of work and time required should not be underestimated. The construction and installation of a full Isolation and Treatment Unit should take no more than one week; in order to achieve this, a relatively large number of artisans and daily workers will be required. The hiring of mechanical excavators (if available) should be considered for the rapid excavation of latrine pits, soakaways, waste disposal pits, drainage trenches, etc. Large quantities of materials may be required and should be sourced locally where possible: Timber poles for fencing, temporary structures, etc. Dressed timber for construction of shelving, benches, stands and supports, etc. Cement, sand, gravel for concreting works. Gravel for paths, etc. 55 Rock for backfilling soakaways. As mentioned previously a functional Treatment Unit does not necessarily require that all infrastructure and facilities be installed at the same time. Depending on the workload and priorities, basic infrastructure can be installed, the Unit can start operating, patient treatment and care can be provided, and improvements can be made later. Two separated rooms (suspect and probable/confirmed) with latrines, waste disposal or storage facility, a changing area, and strict disinfection and infection control procedures can be an acceptable option for the first few days. However, careful planning of the works is essential as the time required for construction and installation will increase substantially if it is necessary to work in contaminated areas wearing full protective clothing. For information on the procedures for closing down the Treatment Unit at the end of the epidemic, see Chapter 15 The End of the Epidemic. Back to Table of Contents 56 6 Hygiene & Infection Control in Outbreak Control Activities This section deals with the use of personal protective equipment, disinfection, infection control, and the management of waste. Primary audience: Medical staff, water, hygiene and sanitation staff. Secondary audience: Coordinators. 6.1 Barrier Nursing and Infection Control The main objectives of barrier nursing and infection control are to prevent transmission of the virus to the following: Medical & non-medical staff Patients’ visitors (and attendants if admitted). Healthy (non-VHF) admitted suspect cases. The wider hospital environment. The public. The purpose of barrier nursing is to create a “wall/screen” that will prevent transmission of disease from an infected person to a non-infected person. Along with infection control, one of the key techniques in barrier nursing is the correct use of personal protective equipment (PPE). The PPE protects the person wearing it. It should completely cover the body, especially the most vulnerable areas: the mucous membranes of the nose, mouth and eyes, and the hands as they are most frequently in direct contact with the patient. PPE should be of good quality, fit well, and be worn correctly. It should be comfortable enough so that no adjustments will be necessary while working in the treatment unit. Transmission can occur with unprotected contact with infectious body fluids such as urine, stool, blood, vomit, sweat, and saliva. Droplets generated by coughing or projectile vomiting can spread through the air for distances greater than 1 meter from the patient’s mouth. However, there is no evidence that the Ebola or Marburg viruses are airborne, but aerosolisation may be possible when sprayers or pressurised hoses are used to clean or disinfect a contaminated surface. See Annex 5.1 Barrier Nursing Principles for information on minimising risks when caring for patients in a VHF Treatment Ward. 6.2 Personal Protective Equipment (PPE) The purpose of the personal protective equipment is to reduce the risk of becoming infected while working in a contaminated area, and to reduce the risk of carrying infected material out of the area. When wearing the personal protective equipment and following the associated disinfection procedures, staff can be confident that it is safe to enter and work in the different riskzones. Sufficient protection is provided to allow the staff to attend to, and care for patients; clean and disinfect buildings, rooms, equipment, and materials; handle and dispose of waste; prepare bodies for burial. Nonetheless, prudent behaviour and adherence to standard and additional precautions is essential in carrying out these activities. 57 For each risk zone, the appropriate protective gear has to be worn at all times. Only persons who are trained in the use of protective gear, and with a valid reason (designated staff, patients’ relatives, visitors, etc.) can be allowed into the treatment unit. Constant monitoring of the use of protective gear is essential throughout the whole outbreak. Everybody must be responsible for themselves, and for checking and monitoring their colleagues. In large outbreaks, consider adding one staff member per shift to check that protective gear is put on correctly before entry; remains correctly in place while inside the high-risk area and that it is removed safely upon exit. Dressing Practice Although the purpose of the PPE is obvious, it is important to understand the function and purpose of the different elements used. A good understanding of the equipment used will give confidence in its ability to protect, reduce any confusion, and help to ensure it is worn and used correctly. An overview of the different items is given below. Scrub Suits (trousers and short-sleeved shirt/tunic) Personal clothing should not be worn under the PPE. Scrub suits are provided so that staff members do not use their personal clothing inside the isolation area. This reduces the risks that contaminated material could be carried outside of the Unit on people’s clothing. The suits are included in the kit, but if necessary due to wear and tear, or if unusual sizes are required, they can easily be copied and made locally. Boots For hygienic reasons, every individual should be issued with their own rubber boots, with their name clearly labelled. This labelling can be useful for identifying people once they are fully dressed if the name on the apron is not visible. The eyes, nose, and mouth are the most vulnerable parts of the body. Therefore, particular attention is required to ensure that masks and goggles fit correctly. If they do not fit correctly, they will not provide the necessary protection. If it is not possible for a person to fit their mask or goggles correctly, then they must not be allowed to enter the high-risk zone. Goggles Goggles must fit comfortably and securely. Goggles must be labelled with the name of the user. Every individual is responsible for ensuring that their goggles are clean and disinfected before putting them on. Consider designating one person to be responsible for ensuring this sort of important disinfection process. A major problem with goggles can be a build up of condensation, which impairs the user’s vision, and is obviously dangerous. However, changing the type of goggle (if other types are available), or using the anti-fog spray provided in the kit can help. Masks Masks must be fluid repellent, comfortable to wear, and seal well to the face. They must maintain their filtration capacity and an easy through-flow of air even when soaked with condensation or sweat. The use of respiratory masks with full beards 58 is not recommended, as an effective seal around the mask is impossible to achieve. High Efficiency Particulate filtration (HEPA) masks are preferred. Overalls and Gowns Overalls and gowns should cover the body entirely, they must have long sleeves and must completely protect the front and back of the body from the neck to the boots. They must be waterproof. Overalls are more secure and allow easier movement than the surgical gowns. However, the gowns are more comfortable, and are adequate where it is culturally inappropriate for women to wear trousers, and when the work being done does not require a lot of bending or lifting. Overalls and gowns should be single use and disposable. Aprons Plastic or rubber aprons provide extra protection and prevent liquids and other material contacting the surface of the overalls/gown. They should be wide enough to extend around the back of the body, and long enough to extend from the neck/upper chest to the top surface of the boots. Aprons should be labelled with the owner’s name for security; it is difficult to recognise people when dressed in the PPE so this labelling is also useful for identification of the staff when dressed up. Symbols can also be drawn on the aprons to allow patients and staff who cannot read to identify each other. Every individual is responsible for ensuring that his or her apron is clean and disinfected before putting it on. Consider designating one person to be responsible for ensuring this sort of important disinfection process (as with goggles above). Gloves The hands are likely to become very contaminated; therefore, gloves are essential. A minimum of one pair of examination gloves is worn at all times in the treatment unit. For safety, a second pair of gloves is worn over the first pair when in the highrisk zone or when performing high-risk activities. The type of glove depends on the tasks being performed: Examination gloves (general duties). Household gloves (cleaning). Surgical gloves (for work requiring particularly sensitive touch). Heavy-duty gloves (waste handling). Gloves must be available in a range of sizes. For security, all gloves should have long cuffs that extend half way up the forearm, and they must be secure, flexible, and tear resistant. They must also be comfortable, simple to disinfect, and easy to remove and change. Head Covers Head covers should be waterproof / hydrophobic, and completely cover the head, hair, ears, neck, and any part of the face not covered by the mask and goggles. The Tyvek hood style head covers in the kit meet these requirements, and have shoulder flaps that provide an extra layer of protection by covering any gap at the collar of the overalls/gown. ! All protective clothing and equipment must fit properly and securely, and it must remain comfortable and in position without requiring readjustment during the time spent in the high-risk zone or while performing high-risk activities. 59 ! The shelf life of gloves and masks is limited. The latex, nitrile, and rubber components can break down, especially when stored in hot conditions. Check them before distributing and using! For further information, see Annex 18 Quality and Requirements for Protective Equipment. 6.2.1 Use of Protective Equipment in the Treatment Unit Low-risk Zone PPE Rubber boots Scrub suit Examination gloves Everybody entering the low-risk zone must remove their street clothes and shoes, and put on a scrub suit, rubber boots, and a pair of gloves. When leaving the unit these items are removed and they change back into their street clothes. This avoids the risk of infectious materials being carried out on people’s clothing. High-risk Zone PPE Low-risk zone protective clothing + Tyvek overalls or gown Apron Goggles Head cover Face mask Second outer pair of gloves (examination, surgical, household, or heavy-duty gloves.) Visitors and Patients’ Attendants PPE Visitors should not touch, or have other contact with patients, e.g. assisting with feeding, bathing, sitting on the bed, etc. However, where patient attendants have to be utilised, contact between patients and their attendants may be unavoidable. The protective clothing requires training and practice in order to use it safely, and it can be uncomfortable. For these reasons, an adapted set of protective clothing, that is easier to use and more comfortable, may be more appropriate for visitors who will have no contact with patients, than the full PPE worn by staff. The adapted PPE should comprise face shield (if available), mask, gloves, gown, and boots. A competent staff member must supervise visitors while on the ward, explain the procedures to the visitors, and assist them in dressing, using the protective equipment, and undressing when leaving. See Annex 13 Information for Patients, Discharged Patients, & Relatives, and Annex 5.2 Dressing & Undressing Protocols. 6.2.2 Use of Protective Equipment outside the Treatment Unit Under normal circumstances, it is not necessary to wear protective equipment outside the Unit. However, certain activities for example burials, house disinfection, hospital disinfection, and patient transport are considered high-risk activities, therefore the same protective equipment must be used as in the High-Risk zone of the treatment unit. However, protective equipment must be used sensibly and appropriately outside of the Treatment Unit. PPE should be donned just prior to starting high-risk activities and removed immediately thereafter. Excessive use of PPE will give the community an 60 exaggerated message about risks and risk management; it may also confuse and dehumanise the community perception of the outbreak response team and activities. 6.2.3 Dressing and Undressing Dressing and undressing must be done in a way that prevents the body being exposed to infectious material, this is especially important for the eyes, nose, and mouth. The order of removing contaminated clothing is the most critical. Under normal conditions, the apron, the outer gloves, and the sleeves of the overalls/gown would be most prone to becoming contaminated. The main principles are that the most contaminated material should be removed first, and the face protection removed last. See annex 5.2 Dressing and Undressing Protocols 6.3 Physical Barriers and Limiting Movement Limit access to the Treatment Unit and restrict movements between different risk zones within the Unit. Put a fence around the Unit, and between the different risk zones. Station guards at the entrances to the Unit and between risk zones. Make clear separations between the different risk zones inside the Unit. See Annex 4.2 Example of Plan of Isolation Facility. It is important to reduce and restrict the movement of people and materials into and out of the different risk zones. Make clear who is allowed to enter which risk zone and who is not. Limit the number of people working in high-risk and low-risk zones. Limit the time staff spend in the high-risk zone, o Maximum shift length 8 hours. o Break every 2 hours. Limit physical contact with patients and material. Avoid sharing material and equipment between the risk zones. Avoid sharing material between patients inside the high-risk zones. Avoid moving from the probable/confirmed patient areas to the suspect patient areas. Ensure that all persons and materials are disinfected if moving from a higher risk zone into a lower risk zone. Clear staffing timetables should be prepared in order to verify who is in the Unit at any time; staff should not be allowed to enter the Unit until the start of their shift to prevent congestion. Consider setting up a staff waiting area outside. 6.4 Disinfection Disinfection can be done in several ways, depending on the availability of disinfectants, disinfection equipment, and systems in place. Chemical disinfection is the easiest and most efficient method of disinfecting large surfaces, protective equipment, waste etc. Practical methods to destroy Ebola and Marburg viruses include: Chemicals: Chlorine based products. (Alcohol and formaldehyde are also effective but are not used by MSF in this context.) Soap: o Special attention must be given to the use of soap as part of the Standard Precautions within the hospital and other health structures. 61 o Care is required to avoid the mixing of soap and chlorine solutions: the efficiency of both is reduced, and chlorine gas can be released. Heat: Steam sterilisation. Ultra Violet (UV): UV from sunlight is active in destroying the virus; laundry can be hung in the sun for drying and extra disinfection. 6.4.1 Chlorine Chlorine is the main disinfectant used in Ebola and Marburg isolation and outbreak control activities. It is the most commonly used disinfectant; it is easy to use, and active against all microorganisms. Chlorine solutions are prepared by a designated person on each shift. When using chlorine, be aware that: Vigorous spraying of contaminated surfaces and corpses can create aerosols, therefore care is required, and full protective gear must be worn. Congealed or clotted blood is liquefied on contact with hypochlorites. Chlorine is corrosive and it is an irritant. Chlorine mixed with detergent loses its efficiency, and may release chlorine gas. Chlorine-based products gradually lose their strength over time. Verify the origin, previous storage conditions, and expiry dates of chlorine products to be used. Chlorine solution made with HTH can damage the sprayers, it is important to clean them regularly; see Annex 5.11 Maintaining Chlorine Sprayers. HTH 70% Granules / NaDCC Large amounts of chlorine solution are required. HTH and NaDCC are the most practical and efficient for preparing the necessary quantities. Household Bleach The guideline “Infection Control for VHF in the African Health Care Setting” (CDC/WHO) recommends the use of household bleach products containing 5% active chlorine to prepare chlorine solutions. However, the strength of household bleach products varies dramatically, and can be found in strengths from much less than 3% up to 5% and sometimes as high as 8%. Moreover, strength deteriorates rapidly depending on age and storage conditions and quality is not guaranteed. MSF recommends the use of HTH or NaDCC. See Annex 5.10 Preparation of Chlorine Solutions. 6.4.2 Chlorine Solutions and their Uses Solution Uses 0.5% Disinfection of body fluids, excreta, vomit, etc. Disinfection of corpses. Disinfection of toilets & bathrooms. Disinfection of gloved hands3. Disinfection of floors. Disinfection of beds & mattress covers. Footbaths. 3 Chlorine solutions can weaken latex gloves and rubber household gloves, therefore latex gloves must be changed every hour, and rubber household gloves must be checked after cleaning, and before reuse. 62 0.05% Disinfection of bare hands and skin. Disinfection of sensitive medical equipment. Disinfection of laundry. Washing up of plates and eating utensils. N.B. The above table recommends using stronger chlorine solutions for some purposes than the CDC/WHO VHF guidelines. Chlorine Preparation Area Storage and Dispensing Stand for 0.5 & 0.05% Chlorine Solutions 6.4.3 Usage and Application of Chlorine Solutions Situation Application Comments Method Care is required to avoid aerosolisation of infectious General disinfection of large material. areas, surfaces, materials. Not for dense material (stools, Disinfection of aprons, boots, 12 litre sprayer vomit). gloved hands, etc. Not for very absorptive material Disinfection of hands. (cotton, fabrics). Sprayers must be corrosion resistant. Care is required to avoid aerosolisation of infectious General disinfection of small material. areas, surfaces, materials. Not for dense material (stools, Disinfection of aprons, boots, 1 litre hand-held vomit). gloved hands, etc. sprayer Not for very absorptive material Disinfection of hands. (cotton, fabrics). Sprayers must be corrosion resistant. Disinfection of excreta, vomit Pouring by cup or Care is required to avoid etc. in bucket/basin. bucket splashing. Disinfection of high volume spill 63 on floor (e.g. vomit). Disinfection of absorptive material (cotton, fabrics, etc) Disinfection of hands. Disinfection of small items. Disinfection of medium sized items. Cleaning of feet at entry/exit of risk zones. Pouring from container with tap Submersing Footbaths Not for large items. Not for large items (mattresses, etc). Their main function is to signal that a different risk zone is being entered. However, footbaths can be useful to clean mud from the boots so that subsequent disinfection by spraying is more efficient. 6.4.4 Chemical Barriers/Sluices Obvious locations for chemical barriers are the changing areas at the entrance and between the risk zones. These chemical barriers serve two purposes: Disinfection of potentially contaminated material (protective clothing, material, waste, etc). Raising staff awareness that they are entering an area with a different risk level. Equipment Required 12-litre chlorine sprayers. o Contain 0.5% chlorine solution to spray boots, apron, and gloved hands. Footbaths. o Contain 0.5% chlorine solution. o Refresh all footbaths at least twice a day, and more frequently if dirty. Hand washing station o Part of the infection control process is the disinfection of the gloved hands. Hand washing tap-stands at the sluices contain 0.5% chlorine solution for gloved hands, and/or 0.05% for bare hands. Rinse gloves or hands for at least 10 seconds, and then use solution to rinse the taps. Air dry gloves or hands. Refresh the chlorine solutions at least twice a day. Hand washing containers must be refilled as necessary to keep up with consumption. 6.5 Water Supply 6.5.1 Quantity Large quantities of water are required for the disinfection procedures, laundry of scrub suits and for general cleaning and hygiene. The water consumption depends less on the number of patients than on the number of staff and the size of the Treatment Unit. Approximately 70l of water per day per staff member working in protective clothing should be calculated. Water is required for the following: Cleaning (with and without soap). Laundry (disinfection and rinsing). Hand washing (0.5% and 0.05% solutions). Foot baths. Disinfection of PPE. 64 Disinfection of materials, beds, buildings, and surfaces. Disinfection and preparation of corpses. Drinking water and preparation of ORS 6.5.2 Water Quality For drinking water and for the preparation of chlorine solutions the water should be clear; turbidity should preferably be less than 5NTU. If turbidity is higher than 20NTU, the water should be treated. Drinking water should be disinfected; the free residual chlorine at the tap should be between 0.3 and 0.5mg/l. 6.5.3 Water Storage Depending on the reliability of the water supply, an emergency buffer of water should be established (a 2 days consumption buffer is advisable) 15m3 storage would be adequate for most situations. 6.5.4 Water Distribution Water is required in all areas of the Unit; install a simple distribution system to supply water throughout the Unit. Manual transportation of water into the different areas and zones should be avoided. All water containers, distribution pipes, and equipment should be made of plastic to avoid damage when in contact with chlorine solutions. Water containers, etc. should be clearly labelled or colour coded to avoid confusion with those containing chlorine solutions. 6.6 Sanitation 6.6.1 Latrines The suspected cases ward and the probable/confirmed cases ward must have separate latrines. If working in an existing structure, the available latrines/toilets may have to be used4. However if possible it is advisable to build temporary, simple pit latrines for the following reasons: 1. The most convenient number and location of latrines can be arranged according to the number of patients and layout of the VHF Treatment Unit. 2. The latrines and the excreta are kept within the compound and more control is possible. 3. Pit latrines cannot easily block; absorbent pads are frequently used and mistakenly disposed into flush toilets. 4. After the outbreak, pit latrines can easily be back filled; septic tanks and sewage systems are more difficult to control. Pit latrines can be constructed with plastic emergency slabs or concrete pre-cast slabs. The slab must be easy to clean and disinfect, and should drain into the pit. 4 If flush toilets connected to a sewage system are utilised, they must be thoroughly disinfected and cleaned at the end of the outbreak. If pit latrines are utilised they should be closed and backfilled at the end of the outbreak and new latrines constructed. If this is not possible due to lack of space, the pit contents should be covered with a 50cm layer of earth and the superstructure thoroughly disinfected and cleaned. 65 The latrine cubicle must be large enough for a patient + an attendant (2.5 m 2) Pit should not be deeper than 2.5 meters (due to risk of collapsing). Bottom of pit must be more than 1.5 meter above groundwater level, to avoid risk of ground water contamination. Minimum numbers of latrines is one latrine per 20 patients and preferably separate latrines for male and female. Staff latrines (male and female) must be available outside the Unit. Hand washing stations with soap and 0.05% chlorine solution must be installed adjacent to all latrines. 6.6.2 Bathing Facilities The suspect area and probable/confirmed area must have separate bathing facilities. Facilities should be split for male and female users. The bathing facility must be easy to clean and disinfect, and drain to a sealed soakaway. The bathing cubicle must be large enough for a large container of water, a patient, and an attendant (2.5 m2). 6.6.3 Laundry Protective Clothing All reusable protective clothing that has been used in the Treatment Unit including scrub suit, apron, and goggles are potentially contaminated and must be disinfected: When exiting the high-risk zone, aprons and goggles are removed and disinfected with 0.5% chlorine solution, then rinsed with clean water before reuse. On a weekly basis (staff member’s day off) or if boots, goggles or aprons are particularly soiled with mud or chlorine residues they should be sent to the laundry for cleaning. Soak in 0.05% chlorine solution for 30 minutes, rinse thoroughly, and wash with detergent, rinse, and air dry. Scrub suits are collected from the changing room and disinfected by soaking in 0.05% chlorine solution for 30 minutes. After rinsing in clean water, they can be washed with detergent. Air-dry in sunlight, as the UV light provides some further disinfection. Bed Linen and Patients’ Clothing Bed linen and patients’ clothing should not leave the high-risk area. These items should be carefully disinfected and laundered in the high-risk laundry area and air-dried. They are disinfected by soaking in 0.05% chlorine solution for 30 minutes, and then washed and air-dried. The clothes of deceased patients should be buried with the corpse, or they should be treated as normal waste and burned. 6.7 Waste Management All waste from the Treatment Unit or from associated activities is considered highly contaminated. Waste must be safely collected, handled, transported to, and disposed of in a secure location inside the high-risk zone. Every effort must be made to minimize risks to the persons handling the waste, other staff, patients, and the community. Staff involved in the management of waste must wear full protective gear. 6.7.1 Waste Segregation Sharps o Immediately after use, all sharps must be placed in specially marked, puncture resistant waterproof sharps containers. 66 o Sharps must never be placed in rubbish bins or bags. Liquid waste o Liquid waste includes; blood, vomit excreta, saliva, etc. o Provide special buckets and/or basins to all patients for vomit, and excreta. o These wastes are very infectious and require special disinfection procedures. Solid waste Dry Waste o Dry waste includes disposable gowns, gloves, packaging, etc. o Provide rubbish bins/bags for collecting dry waste. Wet Waste o Wet waste includes disinfected absorbent pads, dressings, etc. o Provide buckets containing 2cm of 0.5% chlorine solution for collecting wet waste. 6.7.2 Waste Disinfection Locally Made Bag Sharps Stand o No disinfection process required. Liquid Waste o Disinfect with 0.5% chlorine solution. o Disinfect and wash containers after emptying. o Disinfect and clear spills that may occur. o Dispose of liquid waste in latrine or toilet. o Disinfect latrine or toilet afterwards with 0.5% chlorine solution. Solid Waste Dry Waste o Double bag and spray outside of bags. Wet Waste o Place pads etc. in bucket containing 0.5% chlorine solution, then drain, double bag and spray outside of bags. 6.7.3 Waste Disposal Sharps o Seal containers and dispose in sharps pit, or modified drum. Liquid Waste o Dispose in toilet or latrine. Solid Waste o Burn and bury ash in pit. o Fire must be well tended; burner must not be overloaded. o Fire should not smoulder; it must burn hot until all waste has turned to ash. Diesel or kerosene can be added to help the burning process. o Smoke and steam from the fire should not be inhaled. 6.7.4 Waste Storage & Transport Sharps o Store and transport sharps in the sharps containers. o Transport containers directly from the ward to the sharps pit or modified drum. Liquid Waste o Do not store; transport immediately after disinfection. 67 Solid Waste o Transport both dry and wet waste directly from the ward to the burner. o Waste bags can be transported by hand or by placing the bags in a wheelbarrow. o Storage and double handling should be avoided. See Annex 5.9 Waste Management, and Annex 4.6 Waste Disposal & Pits. Back to Table of Contents 68 7 Health Structure Based VHF Patient Management This section deals with the management of VHF patients and the different care options available. Everybody involved in the management and running of a VHF Treatment Unit must have detailed knowledge and understanding of the rationale, rules, and circuits of the functioning of the Unit. Primary audience: Medical staff working with suspect, probable, and confirmed VHF patients. Secondary audience: Coordinators. 7.1 Introduction This chapter contains information on providing quality medical care to Ebola and Marburg patients in a health facility specially prepared for their care. The aim of the VHF Treatment Unit is to provide a safe area for compassionate patient care with exceptional infection control measures that will stop the spread of the infection and contribute towards controlling the epidemic. The effectiveness of the Unit is dependent on its acceptance by the host population; if it is not accepted no patients will come. Acceptance of the Unit will depend on how the population perceives the medical acts performed there. Therefore, it is in the best interest of outbreak control that the isolation ward is operated in a transparent manner despite the isolation measures. Staff must be open and pro-active in communication with the public to demystify the ward and prevent rumours. Furthermore, the medical care provided must be perceived as being humane and of high quality, otherwise the inevitable high case fatality rates will be left to speak for themselves. The case management process starts with the identification of a suspect case in the community or in a health structure, and continues for VHF patients through their recovery and reintegration into the community or their death and burial. For patients who are deemed not to have VHF, their management continues up to transfer of their care to an appropriate medical facility or their return to the community. However, for the purposes of this chapter on health structures set up specifically for providing care to VHF patients, we shall cover the interval starting from the arrival of the suspect to the health facility up to their death or discharge. Although other activities can be carried out by MSF to contain a VHF outbreak, the core of every MSF intervention will always involve providing medical care inside an appropriate isolation structure with the necessary protection and infection control measures. It is important that basic safety conditions be put rapidly in place so that patient care can begin with the minimum delay, and it is imperative that everyone working in the VHF Treatment Unit is well trained in barrier techniques and infection control. If you have not already done so, stop here and read Chapter 6 Hygiene and Infection Control in Outbreak Control Activities. The planning and organisation of the treatment and isolation facilities must be done in a way that facilitates safe working procedures and safe patient care. This is described in Chapter 5 Set-up, Installation, and Organisation of Isolation Facilities. It is important that medical staff provide input, and take part in planning the set-up and organisation of the facilities. 69 The psychological aspects of the intervention must be considered, from the initial assessments, and design of the treatment unit, through to the post-discharge follow-up and support of the patients. This is covered in Chapter 12 Psychological and Social Support. Good communication with patients and families is an essential part of any patient service. In the context of VHF, this is particularly important as it can contribute to improving acceptance of isolation in the VHF Treatment Unit, and other aspects of the intervention. Ambulance services, safe burials, and disinfection of patients’ homes are tightly linked to the functioning of the VHF Treatment Unit; it is important that the medical team understands, and has input in all stages of these processes. The collection and transportation of patients from their homes to the Unit, the death of a patient at home or in the health structure, the disinfection of patients’ homes, and the reintegration of discharged patients into the community must be handled in a culturally appropriate and sensitive manner. This is explained further in Chapter 10 Safe Burials, Disinfection, and Ambulance Services. Health promotion and communication tools for patients and communities in regards to the VHF Treatment Unit and VHF issues in general can be found in Chapter 11 Socio-cultural Issues and Health Promotion. Useful information is also contained in: Annex 1.1 Understanding Filoviruses: the pathophysiology of filoviruses, understanding the diseases, general treatment considerations. Annex 1.2 Diagnosing Filoviruses: lab tests etc. 7.2 Rehumanising the Patient It can happen that at the start of an intervention the health personnel, as well as the community, perceive the VHF patients as “vectors”, and a threat that needs to be isolated and contained. Strict isolation and barrier nursing measures clearly contribute to this view. In our efforts to be safe, we risk dehumanising the patient. It is imperative that compassionate care is provided to all patients within the Unit, and their humanity is respected at all times. Changing attitudes, and re-humanising the patient in the eyes of the caregivers will take time and is probably best achieved through encouraging humane, good quality care, and through contact and interaction with the patients and their families. 7.3 Admission With the arrival of the suspect patient at the VHF Treatment Unit, the first decision that needs to be made is whether to admit them or not. Patients who meet the suspect case definition (or probable or confirmed definitions) are admitted as long as adequate infection control measures are in place to assure their safety while in the Unit (if their safety is not assured, another isolation option will need to be found). However, clinical judgement should play a role in the decision to admit. A patient with obvious measles can easily meet the case definition but have no historic risk factors for VHF. The physician running the VHF Treatment Wards has the final word on who is admitted and who is not. 70 Suspect patients are initially admitted to the suspect area and are treated for other pathologies that may be the cause of their symptoms. The good clinical management of patients awaiting diagnosis is important as they may have potentially curable conditions like malaria. Obviously, the choice of treatment needs to take into account the risk to medical staff, as these patients may well be infected with a VHF (see below). From the suspect ward, they can leave as follows: They have their diagnosis confirmed. They can then be transferred to the confirmed ward. They are shown not to have a VHF infection. They may then be discharged and followed up as a contact5. Due to the limits of the test, this process may take a few days and require repeat testing. They recover with the treatment provided. If the patient makes a full recovery, they need not remain for further testing. Tests on asymptomatic patients are likely to be negative, even in those incubating eventual disease. They may be discharged and followed-up as contacts. If there is no laboratory and if they remain ill for more than 3 days with good medical treatment, or develop symptoms of severe disease (like bleeding). They should be transferred to the probable ward. Inform the patients (and their families) at the time of admission roughly how long the evaluation process will take, and assure them that patients will be receiving appropriate care throughout their stay. 5 All patients staying in the treatment ward should be considered contacts and followed up accordingly. This process must be handled cautiously to avoid alarming the community that has to accept the return of these patients. 71 7.4 Patient Flow Figure 6 - Schematic of Patient Flow The patient arrangement in the VHF Treatment Wards is based on an estimation of their level of risk. A spatial separation of those deemed higher risk improves the safety of those less likely to be infected. Clinical judgement is required to determine this risk estimate until laboratory results are available. Clinicians will have a degree of suspicion of a suspect’s likelihood of having VHF. It is reasonable to arrange the suspect patients based on this judgement Suspect patients generating potentially infectious material, vomiting, having diarrhoea, bleeding, should be separated from those who are not. As a patient’s clinical status evolves, their placement in the ward should change to reflect this. If new symptoms increase or decrease the likelihood of having VHF, the patient should be moved accordingly. If the patient recovers, offer post discharge medical follow-up to the patient. If the patient dies, inform the family about safe burial procedures and, with the family consent, prepare the burial. See Chapter 10 Safe Burials, Disinfection, and Ambulance Services. 7.5 Medical care Whether or not the suspect patient has VHF, their medical treatment begins immediately upon admission. Hydration therapy is started, they are made comfortable, their symptoms are treated, and presumptive therapy is given for other possible infectious diseases. There is currently no specific treatment for Ebola or Marburg haemorrhagic fevers, and treatment is only supportive at this time. Though there is little evidence for or against the effectiveness of supportive care, the patients should receive the benefit of the doubt, and supportive care should be provided. Different levels of supportive care may be provided (see table below). When a VHF Treatment Unit has just been set up, start by providing only the basic oral therapies, and once the unit is running smoothly, a reassessment of the risk of providing injections and IV 72 infusions may allow higher-level care to be provided. These treatments should not be given until the required safety conditions have been achieved. Table 3 - Different Levels of Care Oral Medication & Oral Rehydration The provision of oral medication and rehydration is simple and incurs minimal risk for staff or patients. Providing IV therapy increases workload and exposure risk for the staff and patients. IV Rehydration Before starting IV therapies, all safety measures and protocols must and Other be well established. Everything needed to perform injections or Injection-Related place catheters should be prepared in advance; there should be Therapy adequate lighting, proper patient positioning, and assistance available. Intensive Care The equipment needed to provide the highest level of care (i.e. mechanical ventilation, vasoactive drugs, invasive monitoring, etc.) are unlikely to be available in the settings where VHF outbreaks are most likely to occur. These activities provide multiple opportunities for unintentional infection; they must be carried out with greatest caution. Providing more advanced levels of care may or may not improve a patient's chances of survival, but it clearly involves more risk. The physician in charge of the isolation wards must determine whether this extra risk can be safely managed based upon an evaluation of the skills of the staff, their prudence in carrying out infection control activities, and the safety of the environment. There is pressure to give the patients the highest level of care available to maximise their chances of survival. Even though it is not certain that doing more will have the desired effect, there is an obligation to try our best. There is also pressure to protect the staff by minimising their exposure to risk. Good management of the isolation ward involves creating an environment where the risk to the staff is managed so that they may care safely for the patient using the best means available. Regardless of the level of care available globally, no invasive care is to be provided to an individual patient where a non-invasive alternative is equally effective. Patients that are able to drink should receive oral rehydration, even if the environment is judged suitable for IV fluids to be used. If injected treatments are to be given, medicines with long half-lives should be chosen so that the number of injections given can be as low as possible (e.g. ceftriaxone). Common sense should guide decisions in order to provide the best protection for both patients and staff. Where IV rehydration and other injection therapies are given, rigorous data collection focusing on treatment given and treatment outcome should be conducted in order to gain a better understanding of the benefits of such therapies. At the beginning of the outbreak, it is recommended that a cautious approach be adopted in deciding which staff will perform any invasive procedures. For example, taking blood samples and giving injections should only be done by those staff that are the most skilled and experienced in performing these procedures, and who are well trained in infection control. In making this decision, the level of responsibility of these staff should also be taken into account; staff performing these procedures could be drawn from the managers 73 and supervisors, to avoid the situation where it may be perceived that subordinate personnel are forced to perform potentially dangerous procedures. It should be the aim of a MSF VHF Treatment Ward to provide sufficient staff training and safe conditions to make simple invasive therapies possible (injectable medicines, IV fluids, nasogastric tubes, etc.). However, even if this is achieved, the risks of providing this therapy to confused or aggressive patients should be carefully considered. Patients admitted to a VHF Treatment Ward should be treated using systematic treatment protocols, see Annex 6.2 Systematic Treatment Protocol. The use of these protocols makes the management of these patients easier, but can never fully replace the training and experience of the clinician. It is therefore recommended that the protocols be used flexibly. 7.5.1 Hydration/Volume support The treatment most likely to improve outcome is good fluid management. Ebola and Marburg often have significant GI symptoms, and vomiting, anorexia, and diarrhoea coupled with fever can lead to severe dehydration. Hypovolemia may decrease a patient’s chances of recovering. ORS should be given to patients who are able to drink and assistance provided to assist weak patients. Only when this is not possible should IV rehydration be considered. The risk to staff of giving IV fluids will be small if safety protocols are rigorously followed, but should only be considered when the isolation unit is running properly and the staff are properly trained. Oral Rehydration This is the preferred method of hydration because it is the safest and easiest. Use ORS rather than free water, and give to all patients as required. However, patient factors (weakness, vomiting) may limit the extent to which this route may be used. For patients who are vomiting, anti-emetics should be given and oral rehydration attempted. Prepare ORS for each patient every day, and ensure that the patient and their caregivers understand the importance of consuming as much as possible. Monitor and record the consumption of ORS for every patient. Insufficient oral intake may be an indication for IV therapy in some patients. IV Rehydration When oral rehydration is not possible, IV rehydration should be considered. Keeping in mind, that if a patient is so ill from VHF that their weakness and prostration prevent them from taking oral fluids, it may be that IV fluids will not turn around their course. It should be possible to provide IV fluids in most field settings, but should only be attempted in a well functioning Treatment Unit. When the Unit is completed, and staff members are trained, assess the risks of providing IV fluids. If it is deemed not to be safe, make the necessary improvements (better staff training, better light levels, etc.) and re-assess the situation. The benefits to the patient of providing IV fluids must be weighed against the risks posed to the patient and the staff. These risks must be minimised as much as possible: The set-up should be prepared in advance; there should be adequate lighting, proper patient positioning, and assistance available. Take sharps boxes to the bed. Only use plastic canulas for VHF patients and NEVER metal needles (e.g. butterflies). All canulas must be well secured to avoid the possibility that the line can be pulled out by the patient with resulting contamination by blood of the surroundings. 74 Only well-trained and experienced staff should perform invasive procedures such as giving injections, taking blood and inserting canulas, and there should always be a team of two to ensure safety. Take special care with aggressive or confused patients, if they cannot be controlled and calmed, it is safer to avoid IV fluid therapy. In the absence of good laboratory testing of electrolytes, it is best to use Ringer’s lactate for IV rehydration. Gelofusine can be considered for patients in shock, but concerns have been raised that it may affect blood clotting, and should only be used for rapid volume replacement when necessary. Ebola and Marburg patients typically do not have the most severe form of dehydration, and their rehydration must proceed cautiously. In advanced cases there is also the risk that overaggressive IV hydration may result in pulmonary oedema. Monitor patients receiving IV hydration for signs of over-hydration (e.g. lung crepitus, engorged jugular veins, tachypnoea). Fluid regimes are similar to those for other diseases. A typical regime may be: Bolus therapy. For hypovolaemic adults, one litre of Ringer’s lactate (20cc/kg for children) may be given over 1-2 hours, and the patient re-evaluated afterwards for the need for further IV treatment. Some patients may be able to tolerate oral fluids after a few boluses. Maintenance fluids. For continuous infusion, the rate is dependent upon the patient weight. A typical maintenance regime could be: Adults 40ml/kg/24hr or 3-4 litres per day Children (>20kg) 1500ml + 20ml/kg/24hr Children (10-20kg) 1000ml + 50ml/kg/24hr Children (<10kg) 100ml/kg/24hr These rates may be adjusted based on the level of the volume deficit and patient response. Careful monitoring of therapy is important. IV therapy should be discontinued if signs of over-hydration occur, or if the patient’s condition persistently deteriorates and is likely irreversible, or the condition improves to the point where oral therapy is practical. For further information on hydration, see MSF Clinical Guidelines (on the CD) for treatment of Acute Diarrhoea. 7.5.2 Symptomatic Care All patients can have their suffering and some of their symptoms reduced; these are often severe in filovirus infections and include physical symptoms such as pain and nausea, and psychological problems like anxiety. These symptoms must be actively controlled. Symptomatic treatment is similar to other diseases, although NSAIDs are to be avoided as they may interfere with clotting. 75 7.5.2.1 Pain control Headache, bone and joint pain, chest pain and abdominal pain are all commonly associated with filovirus infections and may be severe. Pain must be controlled quickly. The control of associated anxiety may make pain control easier. Powerful medications like morphine should be made available as soon as possible. Pain Level Mild Pain Medication Paracetamol Moderate Pain Tramadol Severe pain Morphine Dosing Adults: 1 g. PO q. 4-6 hrs PRN Children: 15 mg/kg (IV formulation available) Adults: 50-100 mg. PO/IM/slow IV q. 4-6 hrs PRN Children: do not use <15 years Children and adults 0.1 mg/kg SC q. 4 hrs PRN (may give more frequent or higher dosing as needed to control pain) Remarks Effective for adults and children. (May be included as part of systematic treatment) Effective in adults, but not recommended for children due to lack of safety information. Interactions with morphine, therefore the two drugs should not be given at the same time, so if increasing doses are likely to be needed, it is better to start with morphine. Effective for adults and children. It is useful to have a fast acting form for controlling pain and a slow acting form for maintenance. N.B. – VHF induced hepatic dysfunction presents a theoretical problem with paracetamol as it may interfere with detoxification of the hepatotoxic metabolites, so proper dosing is important. In addition, paracetamol is an antipyretic and should be the only medicine used to reduce fever. NSAIDs (ASA, Ibuprofen, Indomethacin, etc.) are contraindicated in patients at risk of bleeding because of their inhibition of platelet aggregation and due to the risk of peptic ulcer. 7.5.2.2 Nausea and Vomiting Nausea and vomiting are extremely common. Anti-emetic medications may facilitate oral rehydration in patients that are nauseated and vomiting and obviate the need for IV fluids. Oral medication is preferable to IM injections in patients whose vomiting is not severe enough to make PO medications impossible, as IM injections carry all the risks associated with sharps in the setting of VHF. Patients with ileus (mechanical aetiology for their vomiting) are unlikely to respond to anti-emetic therapy Promethazine - included in the symptomatic treatment of adults. It is frequently needed for the treatment of children as well. Adults: 25-50 mg PO q. 6hrs PRN (children 0.5mg/kg) Sometimes this will be not sufficient therefore other medicines, like Metoclopramide can be used. It is recommended to have injectable forms available. Anti-acid medication. Dyspepsia is very common in VHF patients, and prophylactic treatment should be given. Give Cimetidine, ranitidine, or proton pump inhibitors (PPI) to all adults regularly, (PPIs may cause more side effects). 7.5.2.3 Anxiety Anxiety is a common symptom, and admission to an isolation unit is a very stressful event. Anxiety can exacerbate other symptoms such as pain. Psychological support can be helpful, but it is also recommended to use treatments like diazepam in small doses for the short-term management of anxiety in adults. 7.5.3 Presumptive Treatment of Other Diseases The symptoms of VHFs are often indistinguishable from those of other diseases endemic to the regions where VHFs occur, such as malaria, and dysentery. This is especially true 76 of malaria, which is very common in much of these areas. Depending on the dynamics of the outbreak, a significant number of patients in the Treatment Unit may have curable infections, and towards the end of an outbreak, the majority of patients in isolation may have some pathology other than VHF. As conventional laboratory facilities cannot normally be used for VHF patients due to the risk of infection of laboratory staff, these infections are harder to diagnose and patients should be managed clinically. If there is no laboratory present to test for Ebola or Marburg, this becomes especially important, as there will be no negative test result to hint that something else may be the cause of the patient's illness. It is important to ensure that patients do not suffer from potentially curable diseases. If patients recover quickly with treatment for other conditions, the diagnosis of VHF can be considered unlikely and facilitate in their discharge from the isolation ward Patients with Ebola or Marburg may also have concurrent infections with locally common diseases that can interfere with their ability to mount a response to the filovirus infection. As such, all patients should be systematically treated for malaria and with a broadspectrum antibiotic. ACT for malaria. A commonly used regime is 3 days of daily artesunate and amodiaquine. Give this to all patients on admission. Malaria treatment and typical doses are given in Annex 6.3 Malaria Treatment during VHF Outbreaks. Broad Spectrum Antibiotics. Give 5 days of broad-spectrum antibiotics to all patients on admission. Co-trimoxazole or Cefixime are appropriate, however use Cefixime rather than Co-trimoxazole if shigella is prevalent, and suspected. Systematic treatment protocols are no replacement for a clinician's experience and should be used flexibly. At any stage in a patient’s illness, other treatments can be given if other diagnoses are thought possible, although the risk of side effects of over-medication must be considered. An example of a drug prescription form for systematic treatment is given in Annex 12.5 VHF Treatment Sheet. See MSF clinical guidelines (on the CD) for treatment of specific infections. 7.5.4 Other Medical Issues Nutritional Support Malnutrition may be a severe problem in filovirus patients due to anorexia, vomiting, and difficulties with swallowing. This can limit an effective immune response to the filovirus infection and to other pathogens. High-energy foods that are easy to digest, rich in complex carbohydrates and balanced in fat, protein, and fibre should be offered. They must be easy to swallow. The use of NG tubes for nutritional support can be considered. However, feeding must be done cautiously as GI-tract involvement may cause problems with absorption and ileus. Vitamin Supplementation Vitamin deficiency syndromes may compromise a patient’s ability to respond appropriately to VHFs, and correction of any deficits may be beneficial. Retinol (Vitamin A) Adults & children > 1 yr 200,000 IU PO q Day (on day 1, 2, & 8) Children 6 mos. – 1 yr 100,000 IU PO q Day (on day 1, 2, & 8) Becozyme Forte (Vit. B complex) Adults 1 tab per day Children 1 tab per day Ascorbic acid (Vitamin C) 77 Adults Children 250-500 mg PO TID 125-250 mg Alternatively Multivitamin Supplement Tablet 1 tab per day Convulsions – Prevention and Control Patients may convulse, due to VHF or due to other pathologies, e.g. cerebral malaria and meningitis. Convulsions pose a risk to the patients themselves, and may increase the risk of spreading the infection. Consider possible causes of convulsions and offer specific treatment where appropriate. The natural tendency to come to the aid of a seizing patient must be discouraged in the staff. Most seizures are self-limited and should be allowed to pass on their own. Non-medical precautions should also be implemented: pad any hard surfaces near the patient; place the patient at a safe distance from other patients, etc. The best therapy is preventative, and patients at risk for seizures may be given anticonvulsant medication (Phenobarbital) to suppress seizure activity. To control seizures, diazepam should be used. If a canula is already in place and the patient’s seizure activity is mild enough that they can be approached safely the IV route can be used. Otherwise, anticonvulsants should be given rectally. Typical doses are: Phenobarbital Seizure Prophylaxis Adults 5-7mg/kg/day IM Children 10 mg/kg/day IM Diazepam Seizure Control (seizure >10 minutes) Adults 10mg PR (or slow IV), repeated after 5 minutes if convulsions continue Children 0.3mg/kg IV OR 0.5mg/kg PR (max. 10mg) If seizures continue, consider: Administration of 50% glucose. Phenobarbital infusion in 5% glucose (for status epilepticus unresponsive to diazepam): o Adults: 10-15mg/kg at rate of 100mg/min slow o Children 15mg/kg at rate of 30mg/min Reduce infusion rate once seizures have stopped. See MSF Clinical Guidelines (on the CD) for more information on convulsions. Patient Agitation and Confusion Agitated, confused, or aggressive patients may pose a considerable risk to themselves, the staff, and other patients. If patients are allowed to wander aimlessly through the ward, they may infect others or inadvertently be infected. Confusion is likely to be worse at night and the first steps are to increase light levels so that the patients may orient themselves, and try to reason with them in a calm and nonaggressive fashion. If this does not work, chemical sedation may be considered. However, giving chemical sedation to aggressive patients incurs a risk to staff especially at night when staffing levels are lower, also high doses of sedation may be a risk to patients. If it is anticipated that a patient may cause problems during the night, a small prophylactic dose of diazepam (e.g. 5mg for adults) should be considered. 78 If the patient is cooperative and can be reasoned with, oral medication is preferred. Frequently this is impossible and parenteral (IM/IV) treatment is required. Obviously, approaching an uncooperative patient with a sharp needle is very hazardous; it should be done with greatest caution, with overwhelming manpower, and should not be attempted with violent patients except in direst emergency. If IVs are needed, their placement should not be attempted on unsedated patients; IM sedation should be administered and in effect prior to IV placement. Typical doses are: Chlorpromazine Adults 50-100mg IV, IM or PO, half dose in the elderly 25-50 mg IV/PO/IM TID PRN Children 0.5mg/kg Further doses of 25-50mg may be needed, but wait at least 20 minutes before further doses Diazepam Adults 10mg IV q. 1-2 hrs PRN Children 0.3mg/kg IV or 0.5mg/kg PR This can be repeated. Wait for the dose to take effect before giving next dose. This should be at least 20 minutes, and ideally more than an hour. Repeated doses may be dangerous. 7.5.5 Questionable Treatments Sodium bicarbonate The use of sodium bicarbonate to correct acidosis is not safe outside an advanced intensive care unit, and even in this setting, it is not recommended. The only safe way to correct acidosis is via ventilation or renal support, which is impossible outside an intensive care unit. Correcting Hypokalaemia Some data from the Gulu outbreak showed that patients with Ebola HF had hypokalaemia, and hinted that there may be a correlation with disease severity and outcome with the potassium level. There is no established causal relationship, and correction of potassium deficit is not without its hazards and may have no impact on the course of the disease. Those wishing to use potassium supplementation should do so with caution. Oral K + replacement is reasonably safe, and can be considered in situations where there are reasons to believe that the patient may have hypokalaemia (e.g. prolonged vomiting). However, filovirus infections can cause massive cellular damage and renal failure, which may cause these patients to have high K+ levels. RESOMAL is less effective than ORS for normal rehydration, and this treatment should not be routine for VHF patients. Only consider IV K+ replacement if electrolytes can be tested, and if infusion rate control and cardiac monitoring can be done, this is rarely the case in a VHF Treatment Unit. If attempted, a rate no faster than 10 mEq / hour should be used – preferably much slower. Steroids These are not recommended due to possible suppression of the immune response. 79 7.5.6 Experimental Treatments Research initiatives on Ebola and Marburg that are currently undergoing testing include modulators of haemodynamics and vaccines. The field is evolving rapidly, and it is recommended that at the beginning of any epidemic up-to-date information on the status of approval of these treatments is obtained. The use of any therapies in MSF projects that are still considered experimental is to be done only with the approval of headquarters and in conjunction with the appropriate local authorities. The likelihood of severe disease following accidental exposure in a controlled setting like the Treatment Ward may merit the compassionate use of therapies that are still experimental. The availability and approval for these therapies lies outside of MSF. However, the headquarters will be aware of the possibilities and try to arrange to have them on standby in case of emergency need. For further information on potential treatments and vaccines, see Post-Exposure Protection against Marburg - Lancet 9520 2006-04-292.Pdf on the CD. 7.6 Nursing Care 7.6.1 Barrier Nursing and Infection Control A brief description of the measures to be taken is given in this section. Detailed guidance is provided in Chapter 6 Hygiene and Infection Control in Outbreak Control Activities. ! The key principles are to trust the protective gear and to be pro-active in nursing. Barrier nursing refers to introducing barriers that prevent transmission of disease from an infected person to a non-infected person. These barriers can take many forms and includes everything from the use of protective clothing to the full complement of measures utilised in running a VHF Treatment Ward. Infection control is the combination of all the measures to be taken and activities to be implemented to reduce the risk of transmitting infection. The main objective of barrier nursing and infection control is to prevent transmission of the virus: To medical & non-medical staff. Patients’ visitors (and attendants if admitted). To healthy (non-VHF) admitted suspected cases. To the wider hospital environment. To the public. It must be remembered that safe practice and procedures are critical for safety. Indeed, good barrier nursing and infection control procedures are more important than a perfectly installed infrastructure in creating a safe environment for the care and treatment of patients. One separated room for patients, staff trained to safely utilise and remove protective clothing, a sprayer full of chlorine solution, a rubbish bag and a waste pit can function as a VHF Treatment Ward, as long as strict barrier nursing and infection control procedures are implemented. Protecting clothing required in the high-risk area, and for high-risk activities: 80 1. Low-risk protective clothing (scrub suit, boots, and gloves) + 2. Disposable gown or overall + a. Overalls provide the best protection especially for work requiring physical effort and movement. b. Gowns are included in the kit for use in regions where it is culturally inappropriate for female staff to wear trousers. They can be more comfortable than the overalls in very hot weather. 3. High filtration disposable mouth mask (duckbill type) + 4. Disposable head cover + 5. Plastic reusable apron + 6. Goggles + 7. Outer pair of gloves (surgical gloves, examination gloves, household gloves or heavyduty gloves depending on tasks performed). Dressing and Undressing Dressing and undressing has to be done according to the prescribed procedures to prevent unprotected exposure to infectious material. The precise order of dressing and undressing is not critical but must follow bio–security logic. The main principle is that the most contaminated equipment should be removed first and the mask last of all. See Annex 5.1 Dressing & Undressing Protocols. 7.6.2 Prevention of the Spread Infections between Patients of Strict hand washing procedures must be observed after attending to each patient. All patients must be given their own basic items. These individual items must not be shared between patients. These include: o Bowls, cutlery, cups, etc. o Individual thermometers. o Candles and matches (in case of power cuts), soap, towels, etc. Scrupulous hand hygiene and the restriction on sharing items between patients are especially important in the suspect area, where it is likely that there will be patients Provide Individual Patient Items who do not have Ebola or Marburg. ! Medical and support staff must always start their work in the wards by attending first to the patients who are thought to pose the lowest risk of spreading the infection (e.g. people who probably do not have VHF) and progress to those who pose the greatest risk (e.g. actively bleeding confirmed cases). 81 7.6.3 Basic Patient Care As far as possible, nurses should provide all basic nursing care, and not family members, to reduce risk of transmission. This guide assumes that sufficient nursing staff can be hired to provide basic nursing care. If this is not the case, and it is impossible to employ enough nurses, then family members can enter the unit to provide basic supportive care (feeding, bathing, etc.). This is less safe than having trained nurses providing care, and there may be patients who do not have family members willing to enter and help. If family members are to give care, the following must be assured: Only one relative should enter to give this care. He/she is considered as a contact for 21 days after leaving the treatment unit. Protective clothing must be provided and used. Limit the time spent in the ward by family caregivers to one hour at a time. Training on protective measures and protocols must be given. See Annex 13 Information for New Admissions, Discharged Patients, and Relatives, and Annex 5.1 Dressing & Undressing Protocols. o One staff member on every shift must be responsible for providing this training and supervising the caregivers while on the ward. 7.6.4 Patient Monitoring A form is included in annex 12.3 Observation Sheet. There are certain observations that are difficult to do in a VHF Treatment Ward, for example measuring blood pressure. o Stethoscopes may be difficult to use, depending on the head protection worn. Where a choice of head protection is available, those using stethoscopes should choose appropriately. o Stethoscopes should be disinfected between patients, and handled with caution when placing or removing from the ears. o Blood pressure cuffs are difficult to disinfect adequately between patients, therefore their use is not recommended. Temperature and basic symptoms should be recorded twice a day. Record pulse and respiratory rate once or twice a day. Each patient should have their own thermometer; disinfect thermometers thoroughly between uses. Ideally one nurse should do the observations, while another records them. The same procedure should be followed for the doctors’ records. Infection control measures must be respected between patients (disinfecting hands, changing gloves, etc.) 7.6.5 Medication Ideally, drugs with dosing once or twice per day should be used. This allows the limiting of drug rounds to twice per day. Where possible drugs should be prepared in the low-risk area, and brought into the unit in plastic bags. This simplifies infection control, and is especially important for injected drugs. A limited number of emergency drugs may be kept in the unit. Separate stocks are necessary for suspect and confirmed cases. 82 7.6.6 Food Food should be provided by the hospital or MSF, as some patients will not have family to provide food. Food should be appropriate (e.g. easy to digest; rich in complex carbohydrates and balanced in fat, protein, and fibre; culturally acceptable, etc.). This food is brought from the external kitchen and then decanted into another receptacle over the fence of the high-risk area. The container (plastic) inside the highrisk area should be washed and disinfected in this area and it must never leave. Families should be able to bring food for their relative, as this food is likely to be more acceptable to them. A communication officer should be assigned who should be responsible for collecting this food and safely transferring it to the nurses. Give advice to families on which food types are appropriate (see above). For psychological reasons, it may benefit family members to help give food or provide care. However, this is not recommended for infection control reasons, and nursing staff should be the ones who help weak patients to eat. It may be helpful if family members are present when their relatives eat. Sufficient nurses should be available to provide help to patients who are not able to eat independently. 7.6.7 Moving Patients Wheelchairs are useful for moving patients to showers or latrines. Avoid lifting and moving patients by hand; all patients, including children, who are unable to walk, should be moved on stretchers (or sheets if these are not available). Sufficient nursing staff (at least two) should be available when any patient is moved (including children). 7.6.8 Communication with Patients All patients should be briefed on arrival at the VHF Treatment Ward; a national staff member who speaks the local language should do this briefing. It should include some basic information about the disease and the treatment, information on preventing transmission between patients, which latrines they should use, etc. See Annex 13 Information for New Admissions, Discharged Patients, and Relatives. Patients should be encouraged to enter with as few personal possessions as possible (e.g. one set of clothes, no plates etc.). It is helpful to have clothing available for patients within the unit (pyjamas or similar, and clothing to be worn at discharge if they do not have sufficient changes of clothes). Explain that items like plates will be provided within the unit. 7.6.9 Communication with Relatives Good, clear communication with the patients’ families is essential. In the context of an Ebola or Marburg outbreak, good communication is also likely to improve acceptance in the community. An information sheet for patients’ families should be prepared with vital information such as visiting times. See Annex 13 Information for New Admissions, Discharged Patients, and Relatives. Hire someone with good communication skills to facilitate the link to patients’ families. In small Treatment Units, the normal nursing staff may provide this service, but in larger Units, it is helpful to have a specific person for counselling of families during the day. This person must be trained by the psychologists/Health Promotion team. This person: o Counsels the families and is involved in explaining the procedure if they wish to enter and visit family members. 83 o Must be informed regularly about the progress of patients so that this information can be conveyed to the families. o Could also gather information about contacts. Family members should be encouraged to enter the Treatment Ward. This not only provides psychological support for both them and the patients, but also helps people to understand what is happening in the unit and prevents rumours from starting. o The communication officer (or nursing staff in a small Unit) should brief persons entering, and explain the protective clothing. o Family members need to be prepared for what they are likely to find inside, in order to reduce shock. The communication officer should accompany and supervise anxious family members when they enter the Unit. They should wear the same protective clothing as the family members that they are accompanying; they may enter with the reduced clothing as used by family members if there will be no contact with the patient. If family members are unable to refrain from contact then full protective gear must be worn. See section 6.2.1Use of Protective Equipment in the Treatment Facility. Ideally, only one family member should enter at a time. It is easier to manage if the same person visits every time. It may help the families psychologically if more family members enter, but this needs to be weighed against the added risks. Disruption and the workload of the nursing staff is reduced if there are set visiting times. Advise the person entering to minimise contact with the patient and avoid any high-risk activities. Provide a shaded area where mobile patients can talk to family members over the fence. 7.6.10 Psychological Support The psychological well being of patients must be considered. Cheap disposable radios may help for adults, some toys could be provided for children (easily disinfected, and preferably not toys that are shared or encourage running around). Providing psychological support in full protective clothing is difficult. To allow staff to talk to patients without protective clothing, install an area where mobile patients can talk to staff over the fence of the high-risk area. Psychologists or communication officers can provide additional psychological support to patients if requested; this should be done if the patient wants it, but may be inappropriate for severely ill patients. 7.7 Children Providing 24-hour care and psychological support for babies and small children is difficult in full protective clothing. To minimise risks of transmission, the staff should provide the care as much as possible. It should be anticipated that there might be infected children whose parents have died. The care of these children will require more time, therefore sufficient staffing must be planned and organised. However, for the well-being of both children and parents, parents should be permitted to stay in the unit to care for their children. Ideally, one person should stay, but this can cause significant stress. If two family members take turns to give care, there is likely to be less stress but the number of people at risk of infection is increased. 84 It is difficult for parents to stay for long periods inside the Treatment Ward in full protective clothing. Therefore, the length of time spent inside the Ward should be limited to one hour at a time followed by a break of at least one hour. Ideally, parents and small children should stay in a separate area to reduce the risk of transmission. 7.7.1 Mothers with Children There is a high risk that mothers that have filovirus infections will infect their children. Therefore, precautions to minimise this risk must be taken. Breastfed Children If the mother is admitted with symptoms, any breastfed child is probably already infected, but should be given the benefit of doubt. o Separate the child in a special paediatric isolation area. o If the baby returns home, there is a high risk of infecting an untrained caregiver. STOP breastfeeding, but continue stimulation of milk production and relieve breast congestion with a breast milk pump (included in the MSF standard Haemorrhagic Fever Kit). o Artificial milk should be given to the child. Give training on the preparation and use of artificial milk. o Discourage wet-nursing; if the baby breast-feeds from another woman, there is a risk that the baby will develop VHF and infect this woman. The mother may require psychological support. If the child becomes sick and tests positive, then he/she can be returned to the mother. If tests are negative, the child should be retested; if the child remains negative, he/she can leave paediatric isolation ward after twenty-one days. Older Children If verbal and asymptomatic, they should stay at home, and be recorded and followed up as a contact. See Contact Tracing in Section 4.3. 7.8 Maternity Obstetric patients pose special problems in an outbreak. They commonly have vaginal bleeding and are likely to fit the case definitions for Ebola and Marburg, making immediate diagnosis difficult. It is difficult to conduct births in a VHF Treatment Ward. Patients who have severe VHF infections are likely to miscarry. A VHF Treatment Ward is more likely to have abortions or miscarriages than full term deliveries, but basic facilities for deliveries, and a private area to conduct them in, should be installed if possible. 7.8.1 General Recommendations Avoid all invasive procedures as far as possible; avoid or minimise the use of sharps and needles. Use tablets and oral medication; avoid injections. Systematic use of complete protective equipment. o Use uterine gloves (up to the elbow); these can be awkward to use but provide good protection. All exudates, blood, urine, and amniotic material must be treated as contaminated waste, and handled and disposed of safely. 85 7.8.2 Deliveries without Fever No systematic episiotomies; avoid if possible. Systematic prevention of delivery haemorrhage with 10 UI Ocytocine IM after placental delivery. In case of instrumental extraction, do not use forceps; use “suction disk”. Caesarean indication: link with vital maternal indications (e.g. uterine rupture) and not foetal indication. 7.8.3 Deliveries with Fever (suspect, probable, confirmed VHF cases) If possible, wait for the PCR test result. For example, in cases with severe preeclampsia, eclampsia, and dystocia delivery can be delayed for 12-24 hours. If not possible to wait for test result or tests not available, proceed with extreme caution. For further guidance, see Annex 6.4 Maternity and Delivery Guidance. 7.9 Discharge Procedures and Continuing Care 7.9.1 Discharge Criteria for Confirmed Cases In normal situations where patients are recovering, a significant improvement in the condition of the patient needs to be included in the criteria for discharge. Fever is not always a reliable sign in the late and terminal stages of the illness. Therefore absence of fever cannot be used alone to plan discharges of confirmed cases. Typical criteria for discharge could be: Three days without fever or significant symptoms. Significant improvement in clinical condition. Independently mobile and able to feed and wash independently. In the presence of a laboratory, a negative blood PCR may be included as a criterion of discharge. If patients continue to suffer symptoms, but these are not thought to be due to acute VHF, two negative blood PCRs 48 hours apart can be used as a discharge criteria. Discharged patients may remain weak and suffer persistent symptoms. A system for postVHF care and follow-up should be set up for these patients. 7.9.2 Discharge On discharge, disinfect and launder the clothes of recovered positive cases; soak in 0.05% chlorine solution for 30 minutes, and then wash and air-dry. Severely soiled clothes should be burnt. Discharge is easier if replacement clothing is available, family members should bring clean clothes. If practical, disinfect and return other belongings to the patients. Clothes and belongings of non-cases can be disinfected and returned. It is likely that patients’ clothes and belongings will be destroyed upon discharge from the treatment unit and through the disinfection activities at their home. A “solidarity kit” with common belongings and clothes should be provided to make up for this (see Annex 10.2 Distribution of Solidarity Kit). A psychologist or outreach worker should deliver this kit to the home. This activity can be a useful way to gain access to the family, and start follow up and support. The member of staff visiting the patients at home should assess the needs of the family (for example a lack of food if the income earner has died), and ways of overcoming 86 these needs should be considered. Staff should be realistic about their abilities to help in this way, which may be limited. 7.9.3 Supportive Treatment for Discharged Patients Provide one-month supply of vitamin supplements. Nutritional advice. Identify locally available high-energy foods that are easy to digest, rich in complex carbohydrates and balanced in fat, protein and fibre. Provide condoms. Also, provide instructions on using the condoms, and the length of time they should be used (3 months). 7.9.4 Psychological Aspects Anticipate that rejection of discharged patients by their communities may occur. Psychological support and follow up should be considered, including advocacy on patients’ behalf and interceding with community leaders where necessary. See Chapter 12 Psychological and Social Support. 87 7.10 Isolation Ward Management 7.10.1 Information Flow Patient Flow VHF Patient Identification VHF Patient Admission Forms and Documents Triage Form Registration Book Patient’s Clinical File Medical Admission Form Laboratory Results Psychological Notes Observation Sheet VHF Treatment Sheet Epidemiology Epidemiological Form Contact Tracing Form Contact Recording Form VHF Patient Exit Clinical Databases Epidemiological Databases Discharge Form Referral Form Burial Register Death Certificate Figure 7 - Patient and Information Flow Patients admitted to the VHF Treatment Ward should arrive with a triage sheet, (and possibly with a laboratory test result). At the admission, record basic case information in the registration book and open a clinical file for every patient. Epidemiological information must be recorded in individual epidemiological forms. Following psychological assessment, any pertinent psychosocial information should be added to the patient file. On a daily basis, transfer the information contained in the forms and sheets to the databases. Examples of forms and databases can be found in Annex 12 Medical and Epidemiological Forms. 88 Problems can occur with transferring data and information out of the VHF ward. Data and information recorded on paper sheets can not be taken out of the ward, as they are difficult, if not impossible, to disinfect reliably. The simplest methods to overcome this are to dictate the information “over the fence”, or to attach the data sheets to a board that can be read from outside the ward so that the information can be transcribed. This transfer of information should be done at least once per day. Care must be taken to maintain patient confidentiality. In a large ward with many patients, these methods can be laborious and very timeconsuming. Where large amounts of information must be transferred, consider installing a basic laptop or PDA with a mobile modem card or a data-link cable connected to a computer outside the ward for transferring the data. This would greatly simplify and speed the transfer of information, and the cost of a “throwaway” laptop relative to the total cost of the intervention is small. The laptop must be sensibly located and be well protected from chlorine solutions. At the time of writing, a new relational database programme developed by WHO is being field-tested. FIMS (field-information-management-system) shows promise as a customisable and adaptable database tool for collection and analysis of epidemiological information. Check progress of field-testing, and availability of this programme with headquarters. 7.10.2 Information Management While respecting confidentiality, patient information, particularly epidemiological information, must be shared with other organisations in order to facilitate the activities aimed at containing the epidemic (contact tracing, case and cluster investigation, etc.). Handle information in a way that maintains privacy and protects patients and their families from social stigmatisation. For ethical aspects concerning information management, see Chapter 17 Ethical and Human Rights Issues Relevant to VHF. The clinical information can be shared with health authorities. The epidemiological information has to be shared daily with the epidemiological surveillance committee / team. The psychosocial information can be shared with partner organizations working in the social-economical recovery sector. 7.10.3 Case Discussion Meeting The medical people, psychologist, epidemiologist, and watsan MSF team members should meet daily to exchange information about current cases and trends. Inter-agency case discussion meetings can also be held daily. 7.10.4 Waste Management All waste produced inside a VHF Treatment Ward is potentially contaminated, and it is extremely important that waste be managed safely. All waste must be securely collected, transported, and disposed of. Handle waste with extreme caution. To minimise the risk of contamination, transport waste to the waste zone as soon as possible. No waste material should leave the patients’ rooms unless completely disinfected by spraying with, or submersing in, 0.5% chlorine solution. For security, waste should be double bagged before transporting to the waste zone. 89 See Section 6.7 Waste Management. Back to Table of Contents 90 8 Home-based Support and Risk Reduction This section deals with the rationale and approach of providing support to families taking care of Ebola or Marburg patients in the home. It explains when and why this approach may be necessary, and how to reduce the risks of managing and caring for these patients. Primary audience: All staff (medical & non-medical) working on the Home-based Support and Reduction programme. Secondary audience: Coordinators. 8.1 Introduction The aim of Home Based Support and Risk Reduction (HBSRR) is not intended to replace health structure based patient management. HBSRR is an approach that can be considered when care in the VHF Treatment Unit is refused, or is not possible. When assessing the options for care in an epidemic, admission in a VHF Treatment Unit is the preferred option, as this provides more security for the caregivers, and allows better patient care and medical management. However, there are times when care in formal health structures is not an option, and alternatives need to be sought. For example, when the community rejects isolation ward care, or when the geography of the area makes it impossible to transfer patients to a VHF treatment facility. Some comparisons of the two options are given below. Home Based Support and Risk Reduction VHF Treatment Ward Recommended for the safe management of Ebola and Marburg patients. The safest environment for patient care can be constructed. Offers the possibility to care for people in their homes when they do not accept hospital care or hospital care is not possible. Staff can be hired and trained to provide safe care. Safety procedures can be monitored. Patients may communities. Staff may be difficult to find, and be reluctant to provide proper care due to fear of infection. Relies on existing housing in the community, which is unlikely to be ideal. The patient’s family provides care. This is difficult to monitor, and only limited training can be offered to these caregivers. Staff may be easier to find, as relatives provide the care for their family members. May be psychologically difficult for caregivers. Only limited medical care can be offered. May be psychologically difficult for patients and staff. Doctors and nursing staff can provide better medical care. May be expensive and logistically demanding to set up, with large numbers of staff required. suffer rejection within their Takes time to set up properly. Cheap to set up, with fewer staff required. May be difficult to transport patients from remote areas. Can be quick to set up. Easier to organise safe burials. Isolation can be rejected by patients and communities. May be difficult to provide psychological and medical follow up in remote areas, and to supervise safety procedures. Burial teams need to go to the site to manage burials or to collect bodies. When patients live in remote areas, and transport to the Treatment Unit is not possible, HBSRR may be the only way to provide basic care to these patients and to protect their relatives. In this situation, HBSRR teams and community burial teams must be trained 91 and support provided. Training for HBSRR and Safe Burials can be done following an alert in the community, or can be done as part of an enlarged capacity-building approach. If admission to the Treatment Unit is rejected, then HBSRR can be considered. It can help in gaining the trust of the patient, the family, and the community, and in encouraging acceptance of the MSF staff and the health facilities. If transportation of the patient is possible, patients and their relatives should be continuously encouraged to accept admission to the Treatment Unit. 8.2 Recommendations Provide training and equipment to reduce the risk of transmission to the caregiver and the family of the patient. If the situation allows, provide medical care to the patient. If the situation allows, provide psychological support to the patient and family. Many of the details of the care are provided in Annex 9 Home Based Support and Risk Reduction. Management and Monitoring Ensure that the local authorities support the concept of HBSRR, so that they can assist with the necessary facilitation, and share responsibility for solving problems. Monitor carefully the situations in which HBSRR is promoted as an alternative to hospitalisation, by whom, and under which circumstances. The decision to offer this service should be made on a case-by-case basis. HBSRR should only be offered when the possibility of the admission to the Unit has being utterly rejected, it is nonadvisable (for example for patients with aggressive mental disorders), or is logistically impossible. Closely monitor the implementation of HBSRR for any failures such as transmission to caregivers and family members, or deaths that might have been avoided through better treatment. Monitor community reactions, e.g. harassment of HBSRR caregivers and families, and increasing demand for HBSRR. 92 8.3 Patient Flow Usually the flow will be as follows: The Alert officer receives information about a suspect patient in the community or at a Health Centre. If fitting the criteria, an Alert Team is sent to verify the alert; they apply the case definitions to decide whether the patient fits the suspect or probable case definition. If the patient is deemed suspect or probable, he/she will be offered transfer and admission to the VHF Treatment Unit. If the patient refuses admission to the Unit, he/she can be offered admission into the Home Based Support and Risk Reduction program. Information is fed back to the coordination and the HBSRR team visit the patient to provide the necessary equipment and training. If the patient subsequently accepts admission to the VHF Treatment Unit, a safe referral will be organised by the HBSRR team. If referral to a Treatment Unit is logistically not feasible due to transportation difficulties or security concerns: In the location, select and train a local HBSRR team and a Safe Burial team. Set up a monitoring and reporting system to follow the evolution of the cases, and the general situation. Post discharge medical follow-up has to be offered to patients that recover. 93 8.4 Information Flow Patient Flow VHF Patient Identification VHF Patient Admission VHF Patient Exit Forms and Documents Triage Form Registration Book Patient’s Clinical File Medical Admission Form Psychological Notes Follow-up Sheet (Laboratory Results) Clinical Databases Epidemiology Epidemiological Form Contact Tracing Form Contact Recording Form Epidemiological Databases Discharge Form Referral Form Burial Register Death Certificate The forms used for health structure based patient management can also be used for home based support and risk reduction. All patients should be entered in the main patient database. A follow up sheet should be completed at all visits. Usually, the patients admitted to the HBSRR program will have a triage sheet and, when possible, a laboratory test result. At admission, basic case information is recorded in the registration book and a clinical file is opened for every patient. Epidemiological information is recorded in epidemiological forms. After psychological assessment, update the patient file with any pertinent psychosocial information. The information recorded in the forms and sheets should be transferred to the databases each day. Examples of forms and databases can be found in Annex 12 Medical and Epidemiological Forms. 94 8.5 Information Management While respecting confidentiality, patient information, particularly epidemiological information, must be shared with other organisations in order to facilitate the activities aimed at containing the epidemic (contact tracing, case and cluster investigation, etc.). Handle information in a way that maintains privacy, and protects patients and their families from social stigmatisation. For ethical aspects concerning information management, see Chapter 17 Ethical and Human Rights Issues Relevant to VHF. The clinical information can be shared with health authorities. The epidemiological information has to be shared daily with the epidemiological surveillance committee / team. The psychosocial information can be shared with partner organizations working in the social-economical recovery sector. 8.5.1 Case Discussion Meeting The medical people, psychologist, epidemiologist, and watsan MSF team members should meet daily to exchange information about current cases and trends. Inter-agency case discussion meetings can also be held daily. 8.6 Reducing the Risk of Contamination The primary aim of home based support and risk reduction is to reduce the risk of transmission to the patient’s family by providing training and equipment, followed by a series of support visits to the patient’s home. The first visit should be scheduled to allow sufficient time to provide adequate training, and to discuss the option for transfer to the Treatment Unit. The nature of the disease and reasons for risk reduction need to be explained to the patient and the family. Identify one family member to provide the care; a single caregiver is chosen in order to allow a thorough training and follow up, and to minimise the number of people at risk of exposure. A watsan must attend the first home visit and participate in the training. Identify an area or room within the family home where the patient can be isolated. Ideally, select a separate structure; if this is not possible and the home does not have separate rooms, create an isolation area by dividing and partitioning the building. Only the caregiver will be allowed to enter the isolation room during the illness. A separate latrine should be available for the patient. If this is not possible, the patient can use a potty or bucket containing 0.5% chlorine, which can then be transferred to the family latrine. Dig a pit for the disposal of waste; this pit should be covered. Brief the caregiver on the procedures they must follow. They must be available to provide care for the entire duration of the patient’s illness. They must be thoroughly briefed on the protocols (see Annex 9.2 Caretaker Task Instructions). Sufficient protective equipment and disinfection materials must be provided. The procedures are likely to be alien and difficult to understand for the caregivers; follow up regularly, ideally every day if the geography and number of staff allow. Discuss the caregivers concerns, ask questions about how care is given, and provide further information and training as necessary. 95 Initially, an expatriate medic should do this follow up, although with training it should be possible to transfer most of the duties to national staff. The watsan should continue to attend some of the follow up visits. The staff involved in the service must not be put at risk. They should avoid entering the room where the patient is being cared for, unless it is essential and they are properly protected. If the staff members do not enter the patient’s room and they have no direct contact with the patient, they can work in normal clothes. Training should be conducted outside of the house. Children Sick children will pose significant problems and home care will be difficult if not impossible. If the relatives or parents of a sick child refuse admission to the VHF Treatment Unit, MSF should inform the authorities who should guarantee respect of the child’s right to receive treatment. It should be anticipated that there might be infected children whose parents have died. It will be difficult for parents to stay for long periods in full protective clothing inside the room where a child is isolated. Therefore, the same reduced protective clothing as provided to visitors inside the VHF Treatment Wards should be considered. If mothers of small children are infected, separate the child from the mother to reduce the chance of vertical transmission. o If the child is asymptomatic, follow up as a contact. If the child has fever, assess for VHF. o If the child becomes sick and tests positive, then he/she can be returned to the mother. STOP breastfeeding, but continue stimulation of milk production and relieve breast congestion with a breast milk pump. o Artificial milk should be given to the child. Give training on the preparation and use of artificial milk. o Discourage wet-nursing; if the baby breast-feeds from another woman, there is a risk that the baby will develop VHF and infect this woman. The mother may require psychological support. 8.7 Case Management 8.7.1 Medical Care The patient’s medical condition should be discussed with the caregivers. However, due to the risk of exposure to the staff, the medical care that can be provided in this situation must be limited. Staff members should only attempt to review the patient after ascertaining that there will be minimal risk in entering the patient’s room. If it is not possible to review the patient then they should give treatments based on the symptoms described by the caregivers. Due to the obvious limits posed by this restriction, it is very helpful to treat the patients according to the systematic treatment protocols (as described in Annex 6.2 Systematic Treatment Protocols. Additional treatments such as painkillers can be provided, and the family can be provided with ORS for rehydration. However, if complex treatments are requested or required, the patient should be persuaded to seek further help in the Treatment Unit. 96 8.7.2 Psychological Support The system of home-based care may put considerable strain on the caregiver and the family. The normal stress of having a family member seriously ill will be compounded by their fear of the disease, and the dangers posed by providing care. Furthermore, the family may suffer stigmatisation and rejection by neighbours and the surrounding community. It is important that psychological support be given to the caregiver. Without this support, they may not be able to complete the care. It may also be necessary to provide information and reassurance to the surrounding community. A trained psychologist, if available, should start this support, although the follow up may be handed over to trained national staff as the project continues. The psychologist should be present at the first visit, and subsequently visit periodically. 8.7.3 Admission and Discharge Criteria The admission and discharge criteria are similar to those given in the section on health structure based patient management. When a laboratory is present, formal laboratory diagnosis can aid the decision making process. However, it may be difficult to take laboratory samples in the community. Oral swabs are easier to take, but are more difficult to test. Dressing up in the protective clothing to take samples at the first encounter with the patient may increase their fear. However, laboratory diagnosis is recommended if a laboratory is available. Repeat samples may be needed, as described in Annex 1.2 Diagnosing Filoviruses. In the absence of a laboratory, patients are assessed using the case definitions. Every patient should have their history reviewed by a clinician, as some patients can be ruled out clinically. The discharge criteria should be similar to those used in the Treatment Unit. It is unlikely to be practical to take discharge laboratory samples from HBSRR patients, so their clinical state should guide the decision. Typical discharge criteria would be: Three days without fever and only very mild symptoms. Clinical improvement in the patient’s condition. Able to move and care for themselves independently. Fever is not always a reliable sign on its own and must not be used alone to guide decision-making. 8.8 Burials Carefully brief the caregivers on the need for safe burials in order to prevent risky funeral practices if the patient dies. Frequent follow up visits and good communication are required, to ensure that burial teams are alerted promptly if a death occurs. If home based care is used in remote areas where follow up is more difficult, it may be impossible to arrange safe burials conducted by the burial teams. In these situations, other options should be considered, for example, training the community to conduct burials safely. See Chapter 10 Safe Burials, Disinfection, and Ambulance Services 8.9 Human Resources Staff Expatriate medic (nurse or Duties Leads the team and is responsible for the medical 97 doctor) Expatriate watsan Expatriate psychologist National nurse / communicator management of the patients. Provides training and advice to the caregiver. Provides advice about infection control and safety procedures, and waste disposal. Should attend the first visit to the family, and perform follow-up visits as required. Provides psychological support to the caregiver and the family, and information to the community as required. Must attend initial visit to the patient, and then perform follow up visits. Provides support to the team and improves communication with the family. With training may be able to take over much of the follow-up work of the expatriate medic. Driver Back to Table of Contents 98 9 Infection Control outside the VHF Treatment Facility This section deals with implementing and improving infection control practices in hospitals, health centres and other health services in the outbreak area. It explains the need for, and implementation of, effective triage procedures, and basic requirements for infection control and supporting activities. Further guidance can be found in the MSF Infection Control Guideline. Primary audience: Medical, WHS, and infection control staff. Secondary audience: Coordinators. 9.1 Introduction It is necessary to implement an Infection Control programme in order to: o Transfer skills and responsibilities to local professionals for responding to an outbreak. o Reinforce health workers’ capacity to correctly identify, manage, and refer suspect Ebola and Marburg cases. o Create a safe working environment in the health structures. Large outbreaks are often associated with nosocomial spread in the formal health care system, and it is common for large hospitals to become involved. Outbreaks occur in poor countries with a high burden of disease; it is likely that the epidemic will not be the main cause of death in the community, with diseases like malaria continuing to have a high death toll. It is therefore advisable that the essential (emergency) health services remain operational during an epidemic. Other services, like vaccination, should continue to run if they can be provided safely. Infection control procedures in hospitals and health structures in less developed countries are often very poor, and put patients and staff at risk. It is recommended that procedures are assessed and that interventions are undertaken to improve deficiencies. In hospitals, a triage system needs to be set up, so that suspect and probable patients are identified and isolated from the others to avoid the spread of the disease. The triage and infection control activities in health facilities should be done in a manner that minimises fears within the community; the community should be reassured that they can safely continue to access essential services and receive treatment for serious diseases. Unsafe injection practices in health centres (and elsewhere) can be a cause of nosocomial transmission, therefore consider this when planning the district-wide infection control strategy. 9.2 Assessment and Intervention Criteria The successful implementation of infection control improvements may be expensive and require the inputs of many staff. MSF should only take responsibility if adequate control is possible and the hospital management gives the necessary authority to act. It is therefore essential to involve the relevant authorities in planning any assessment and intervention. The co-operation of those responsible for the health structures is essential for a successful intervention. Ensure agreements are clear about the amount of authority and supervision that MSF can assume. In principle, all established health structures should be assessed. A priority list should be prepared of facilities to be assessed first. Facilities that conduct invasive procedures and curative services have the highest priority. 99 Hospitals have a high risk because severely ill patients are admitted to them, and this is very likely to include Ebola and Marburg cases. Health centres (both public and private), especially those with inpatient and minor surgical services. Dentists, laboratories, pharmacies. Vaccination services should be assessed. 9.2.1 Assessment Procedure An MSF team comprising an experienced medic (doctor or nurse) and a person experienced in water, hygiene, sanitation (and preferably isolation and infection control) should carry out the assessments. The following should be assessed: General structure, and activity of the facility: o Architecture, layout, and state of repair. o Services offered (surgery, maternity, laboratory, EPI, etc.) o Attendance rate, number of patients, number of beds, etc. Triage procedures for the identification of VHF patients. Existing infection control procedures, adherence to standard precautions, hand washing facilities and practice, etc. Sharps and waste management procedures, excreta disposal, wastewater management, etc. Cleaning and laundry procedures. Water supply. Staff organisation and numbers: qualifications, job profiles, schedules, etc. Availability and management of equipment and materials (gloves, protective equipment, etc.). Flow of patients, staff, and visitors. Discuss findings and recommendations with the relevant local authorities. Criteria for MSF involvement in infection control include: A risk of nosocomial spread identified in the facility examined. Clarity on where and how MSF can improve current infection control procedures (e.g. triage, standard precautions, distribution of clean needles etc.). Lack of local capacity to make the necessary improvements (also lack of other NGOs working in the area who are willing and capable of making these improvements). Clear agreement with the relevant authorities regarding power to act and the use of donated materials. 9.3 Hospital Infection Control and Triage 9.3.1 Rationale The aim of the intervention is to: 1. Prevent the spread of filovirus infections within the health structure. 2. Minimise disruption to the normal hospital functioning. 3. Maintain the population’s good access to health care. The hospitals involved are unlikely to be under direct MSF control or supervision, so diplomacy and tact are necessary to create and maintain good relations with the hospital 100 authorities at national and local level, and the independent organisations that manage the private and religious hospitals. To assist in the development of these relations: The hospital authorities must be involved in the planning of activities. Set up an Infection Control Committee comprising members of the hospital management, health and support staff and MSF. They should meet regularly to discuss the planning and implementation of activities. MSF must be flexible in its approach. It is vital for effective implementation to maintain good relations with the hospital staff. Demonstrate respect for local knowledge, skills, and practices, while giving clear explanations about interventions and objectives. General principles include: Be clear about the objectives; only try to change local protocols when it is relevant to achieving those objectives. Work in a collaborative manner with local staff, and be respectful of their opinions. Interventions to improve infection control will involve the following issues. 1) Organisation a) Infection Control Committee and Teams. b) Reduction of hospital activities. c) Supervision and training. 2) Early case detection a) At admission (Triage). b) Active search of in-patient wards. c) Mortality review. 3) Disinfection and transfer of suspect cases. 4) Standard and additional precautions. a) Hand washing. b) Hand gloving. c) Use of personal protection equipment. d) Safe Use and processing of patients care equipment. e) Cleaning. f) Safe linen handling, transport and processing. g) Safe working practices: i) Safe injection procedures. ii) Safe handling and disposal of needles and sharps. iii) Safe handling and disposal of medical wastes. 5) Patient placement. 6) Patient transport. 7) Visitor access and precautions for family members providing care to patients. 8) Medical protocols and reduction of invasive procedures. 9) Water supply. 9.3.2 Organisation Infection Control Committee and Teams In large health facilities and hospitals, it is advisable to create an Infection Control Committee (ICC) with Infection Control Teams (ICT) if not already existing. In smaller health facilities, a person with experience and training should be appointed to carry out the main tasks of the committee and the infection control team. The Infection Control Committee is responsible for the elaboration, implementation, and follow up of protocols and recommendations. They should meet weekly or more often to address particular problems that may arise. 101 MSF should be part of the ICC and depending on needs and circumstances can be in charge of triage, patient flow, infection control and isolation procedures, including logistics, stock management, and water and sanitation activities in all hospital services. Regardless of MSF presence, the hospital manager is ultimately responsible to ensure the good functioning of the infection control programme. The ICC should include: The hospital director. The medical director. The head nurse. The head of technical services. The head cleaner. Representatives from the various hospital departments. In addition, potentially: The administrator / financial controller. A health authority representative. A local authority representative. A community representative. The infection control team comprises: One Triage Supervisor. One Standard Precautions Supervisor. One Hygiene Supervisor. They are responsible for day-to-day supervision and decisions on infection control as well as long term planning. This team should inform the committee about the situation in terms of infection control in each department. They should meet several times a week or daily if possible. An infection control programme will only be effective if all the health staff play their part in the process and the implementation. To encourage this, provide regular feedback to the staff in charge of each hospital department. The most important activities to ensure adequate infection control practices are: Provide equipment that enables the staff to maintain good infection control practices (protection equipment, waste disposal materials, cleaning and disinfection materials). Provide protocols for procedures used within the health care setting (safe injection practices, invasive procedures, etc.) Implement training programmes for all staff including on the job training and formal training sessions. Establish surveillance systems that identify problem areas (monitoring checklists). Produce guidelines for cleaning, disinfection, and waste disposal, and ensure adherence to those guidelines. 9.4 Restriction of Hospital Services and Closure of Departments Closure of hospitals or hospital departments reduces the risk of nosocomial transmission of Ebola or Marburg. However, these viruses are not the sole causes of mortality and morbidity during an outbreak; it is important that the population have access to essential life saving procedures. Furthermore, if hospital services are closed, patients are likely to seek treatment elsewhere. The options open to such patients will probably be limited to the informal health sector that is more difficult to monitor and supervise. Clearly, the decision to restrict or close hospital services must be carefully considered; closure of 102 hospital services risks increasing transmission of infections in the informal health structures and services. Therefore: Every effort should be made to improve infection control and hygiene practices in the hospital so that essential life-saving services can remain open. If the risk of contamination and transmission in any particular service remains at unacceptable levels, consider temporarily closing that service. If essential services are closed, prioritise improving the infection control and hygiene precautions so that the closure can be as short as possible. Provide alternative services and/or facilities during the closure period. As a general principle, it is better to maintain as many hospital services as possible, so that patients can be treated in a controlled environment where contamination risks can be minimised. Planning must always take into account the general public health situation, and not concentrate solely on the outbreak. Services that should be regarded as essential include: Maternity. Emergency. Paediatric acute medicine. Adult acute medicine. Essential surgery. Trauma. Other services that should be considered include: Laboratory services (other than for VHF diagnosis). Treatment of chronic diseases such as TB and HIV. This should be done at home where possible. An alternative to complete closure is an appropriate reduction or adjustment of the service provided; this can include giving treatment at home where appropriate. 9.5 Triage and Early Detection of VHF Patients Early detection and isolation of VHF patients is essential to reduce the risk of hospital transmission, and is a key point in the infection control process. Start this as early as possible, and follow up closely in order to minimise the spread of the disease. This must be done in a manner that minimises the impact on the normal functioning of the hospital, and takes account of psychological and social factors that may result in the hospital becoming less acceptable to the host population. Implement case detection at three levels: 1) Admission: screening based on the application of a suspect case definition to every patient that arrives at the hospital. 2) Inpatient departments: active searching for cases presenting with fever or sudden worsening of their general status after admission. 3) Mortality review: review of all deaths in the hospital before proceeding to burial. 9.5.1 Admission Triage This service must operate 24 hours per day. 103 The suspect case definition is useful as a screening tool to detect patients who need further assessment. The screening is carried out by health staff upon admission to the health facility according to a standard triage form based on the suspect case definition (see Annex 12.1 Triage Form). The triage form includes axilar temperature measurement. All patients should be screened. Only cases verified in the community by specific alert teams will be sent directly to the Treatment Unit. All patients meeting the suspect case definition are referred for further assessment. While awaiting this assessment they must be separated from other patients, and no invasive procedures should be attempted until their status is determined and safety is ensured. Should the patient fulfil the suspect criteria, he/she will be transported to the Treatment Unit for further assessment, testing, and treatment. The admission area must be disinfected immediately afterwards. If VHF is discarded, health staff will evaluate the severity of the patient and send him or her to the most suitable health facility (peripheral health structure or a specific hospital department). If MSF is leading the activity, a medical expatriate should supervise the triage and assess suspect patients 9.5.2 Organisation of Admission Triage Activities All patients should go through triage before being treated by the relevant service. There are three basic strategies available: One triage point. All patients entering the hospital pass through one common point for screening. o This has the advantage of being easier to supervise, and fewer expatriate staff are required for supervision. o A high quality triage can be achieved, and suspect patients can be taken directly to the Treatment Unit without entering other departments. o However, there may be detrimental effects on the functioning of the hospital and on acceptance by the community. o Maternity may pose special problems (see below). Triage points in each hospital service. This may be more acceptable to the local community, as it will be similar to the systems to which they are accustomed. Other considerations include: o Obstetric patients may not want to queue with sick people at a common point, as they do not regard themselves as being ill. o The general effects on the hospital functioning may be less. o Existing nursing staff in these departments perform the triage activities. o It may be difficult to organise the normal assessment of patients and triage for suspect VHF cases. o Suspect patients enter the departments before referral to the Treatment Unit (with the subsequent need for disinfection). A combination of the two systems. The two systems may be combined, for example, a triage point in maternity, and one other point for all the other services. This allows some of the advantages (and disadvantages) of the two systems to be combined. The choice between these options depends on a number of local factors, and the decision should be made with the local authorities. Some relevant factors to decision making are: 104 Cultural factors and the acceptability to the local population; having all patients passing through one triage point may increase fear and reduce hospital attendance, or conversely it may improve confidence and attendance. The number of trained and experienced staff available to do supervision. The wishes of the health authority. The size of the health structure, the services provided, and the existing circuits within the structure. 9.5.3 Organisation of Triage Points Triage points must be open, well lit, well ventilated, spacious, and easy to disinfect. Where a single triage point has been installed, separate queues for children, adults, and maternity may be helpful. Arrange an entrance for ambulances; patients arriving by ambulance must also be triaged. Consider the route and access to the VHF Treatment Unit for ambulances. Fencing the entire health facility may help stream all patients through triage. Access to the hospital should be restricted; limit access to identified staff and patients, and limit the number of visitors. Organise guards to control crowds, and to guide and control the flow of patients and visitors. 9.5.4 Other Considerations Transfer of Suspect Cases from Hospital Triage When a suspect case is detected in the Hospital triage, they must be referred directly to the Suspect Area of the Treatment Unit. However, there is a possibility that the patient will refuse to go directly to the Unit, as they may be afraid of having the disease confirmed. Counselling and a clear explanation of the subsequent procedures should be provided. Safety Room in the Hospital Where there are serious problems with patients refusing referral to the VHF Treatment Unit for further assessment, the installation of a Safety Room can be considered. This is a room set aside in the hospital for the evaluation of suspect patients. Blood can be drawn and symptomatic treatment provided. Infection control and the use of personal protective equipment must be implemented to the same standard as in the Treatment Unit. However, this approach can be problematic. It is recommended to refer the cases from triage directly to the Suspect Area of the Unit and avoid the use of a Safety Room for the follow reasons: To avoid creating an infection point in the hospital. Extra medical staff trained in VHF case management are required outside the VHF Treatment Unit. Extra supervision is necessary to ensure infection control, and use of PPE, etc is implemented correctly. The workload is increased, (disinfecting the room after each use, transfer of patients, etc.). Maternity Patients Maternity patients may pose special problems for the triage system. These include: A large number of maternity patients present with bleeding. This means that many will meet the VHF case definition when in fact they have other conditions. It may not be appropriate to assess all these patients in the VHF Treatment Unit. 105 The VHF Treatment Wards are likely to be poorly equipped to do deliveries. Therefore, it may be damaging to non-VHF patients to be assessed in the Treatment Unit. Maternity patients may not regard themselves as being ill, and could object to being assessed with other patients. Bleeding maternity patients may cause extra anxiety to other patients in a common triage area. For these reasons, special planning is necessary. If maternity patients are assessed with other patients, a combination of cultural factors and unnecessary admissions to the Treatment Unit may cause a rejection of maternity services, resulting in non-VHF patients avoiding life-saving services, and VHF patients staying at home. However: Ebola and Marburg patients may present with miscarriage. In populations where many women are pregnant, it can be anticipated that there will be women presenting with miscarriage. Normal births have a much lower chance of being VHF cases than miscarriages or abortions. Depending on the circumstances of the hospital, it may be appropriate to triage these patients in maternity and have a special holding area or mini-isolation unit in maternity for suspect patients. In the absence of a laboratory, this approach will be difficult, as patients will not receive a rapid formal diagnosis. Evaluate the possibility and pertinence to install a Holding Area or Safety Room for suspect cases in the maternity service. If a holding-area is to be set up in maternity: A changing area is required. A delivery room should be installed within the holding area, respecting all the safety and disinfection procedures. The staff of the maternity ward must be willing to be trained, and they must be willing to provide care to the patients isolated there. If the midwives refuse to provide care, the system will not work. Careful training of the midwives must be provided in the use of PPE, barrier nursing, infection control, and disinfection techniques. The midwives working in the holding area should not work with other patients during the same shift. Equipment should be provided as required. Testing should be done, and the patient should stay until the result is known. 9.6 Detection of Patients after Admission All VHF fever patients should be detected by the triage system. However, this may not always be the case. A system of checking patients admitted to the wards is advised; fever control should be done for all in-patients. 9.6.1 Procedure All patients, irrespective of diagnosis, should have their temperature taken at least twice, and preferably three times, per day by the health staff of the inpatient department. If this cannot be arranged, a specific team can be organised to carry out this task under the responsibility of the infection control team. MSF expatriates should pass through the wards and talk to the nursing staff. They should review patients who are of concern to the nursing staff. If the patient has a 106 possibility of VHF, they should be referred to the Treatment Unit. If they are thought not to have VHF, this should be communicated to the nursing staff. Fever patients should be reviewed, including all patients who develop fever unexpectedly. Any patient presenting sudden worsening or fever (tª > 37.5°) must be immediately re-evaluated to determine whether referral to the Treatment Unit is required. o If not thought to be a suspect case, the evolution of the treatment should be followed. o If thought to be a suspect case, they must be referred to the Unit for evaluation and testing. Transfer of the patient must be done safely and the room must be disinfected. 9.7 Transfer of Suspect Cases to the VHF Treatment Unit When a suspect case is identified in one of the triage points or in a ward, they must be transferred to the VHF Treatment Unit. To prevent contamination and spreading of infection an ambulance/disinfection team should do the transfer, and disinfect the area where the patient was accommodated. In the maternity, special care has to be taken; it may not be culturally acceptable for male staff to attend to these patients. 9.8 Deaths Occurring in the Hospital Taking care of dead bodies that are present in public or hospital morgues is one of the very first priorities. Burying the bodies and disinfecting the morgue are essential, and should be done as quickly as possible; this is an integral part of setting up the infection control and triage systems. The handling and preparation of corpses for burial is one of the highest risk activities for the spread of the epidemic, therefore great care is necessary. The corpses of people who have died of Ebola or Marburg contain very high levels of virus. The VHF status of dead bodies may be difficult to determine, therefore a cautious approach must be taken. Full protection must be used and rigorous infection control must be done. If there is a VHF laboratory on site, it may be possible to test bodies; those testing negative should be disinfected and can be returned to the relatives for normal burials. It can happen that people will be scared to collect the bodies of their relatives from the hospital or morgue, even if they have not died of Ebola or Marburg. Burials must be organised, and relatives should be informed when and where the burials will take place, and they should be encouraged to attend. While the morgue is being cleared of bodies and disinfected, an alternative temporary morgue area should be prepared to store the bodies of the non-VHF deceased. Analysis of mortality in the hospital is important in order to detect contacts (non-admitted caregivers, other patients, and health staff) and to guarantee safe burials of VHF suspect cases. Once the infection control and triage system is put in place, all deceased patients should be reported to the Infection Control Team before the body is sent to the normal mortuary or given to the family. This may prove difficult with children, who are commonly carried away by the family shortly after death. The triage procedures described above can be used to screen the body to see if there is a risk of VHF (review the clinical history and 107 decide). The infection control team will evaluate every case and decide if it is a suspect case or not. All cases, whether suspect or not, must be recorded. If there is no suspicion of VHF, a declaration form will be given to the family certifying that the patient was evaluated and VHF was ruled out. Any case with suspicion of VHF should be safely transported to the VHF mortuary by a burial team and the patient’s room disinfected. If a family member is present, they must be informed of the procedures that will be followed and the reasons why they are necessary. Sensitive and clear communication with the family is vital, and it is essential that someone with good communication skills explain the process to them. Once in the mortuary the body should be tested if a laboratory is available. An oral swab is normally the most appropriate test available. Testing the body helps ensure: That bodies testing negative can be returned to the family for normal burial (although if there is any doubt about the diagnosis they should be treated as positive). A negative test result form should accompany bodies that have tested negative, this will ease any further investigation by epidemiologic surveillance teams Bodies that have tested positive can be handled and buried safely. Disinfection of the ward/house (if the patient was at home recently) can be done. Contact tracing can be done for family members. The family is left in no doubt as to the VHF status of the patient. Burial protocols are described in Annex 11.3 Guideline for Safe Burial Practices. 9.9 Standard Precautions and Training of Staff Application of standard hygiene precautions should be normal procedure in all hospitals and health structures. The implementation of Standard Precautions is the primary strategy for achieving nosocomial infection control by reducing the risk of transmission between healthcare workers, patients, attendants, visitors, etc. Standard Precautions are necessary for the care of all patients in health structures regardless of their diagnosis or presumed infection status. Additional precautions are required to reduce the risk of transmission of VHFs. See Section 1.3.3 Reinforcement of Standard & Additional Precautions in Health Structures Specific information concerning many infection control topics can be found in the MSF infection control manual. If agreed by hospital authorities, training and supervision of these topics could be provided by MSF nursing staff. Specific points include the following. 9.9.1 Wearing of gloves This helps to protect the person wearing the gloves, but the gloves need to be changed or disinfected (in 0.5% chorine) after each patient to prevent the transfer of infection between patients. Gloves should also be changed after contact with blood, body fluids, secretions, excretions and contaminated material or in case there is any damage to the glove. Hands must be washed with 0.05% chlorine solution each time gloves are removed. During outbreaks, double gloving is adopted 108 9.9.2 Hand Washing This is very important for the prevention of transmission of infection between patients. Gloved hands are washed in 0.5% chlorine solution, un-gloved hands in 0.05% chlorine. Wash hands immediately with 0.05% chlorine solution after gloves are removed, and when otherwise indicated. Remember that gloves do not substitute for hand washing. Multiple hand washing stations with 0.5% and 0.05% chlorine solution must be conveniently located in all patient care areas. 9.9.3 Personal Protection Equipment (PPE) Gloves, face shields or goggles, masks, gowns, heavy-duty gloves, rubber boots) should be provided in adequate quantities to allow personnel to change gloves and gowns regularly. Equipment used should be appropriate to the risk and the task being done. This equipment should be removed upon leaving the work area. All staff must be trained in the use of the PPE, and dressing and undressing procedures. The overuse and misuse of PPE is a risk, supervision is important to avoid this happening. It is very important to ensure a reliable supply of protective equipment to the whole hospital in order to implement the standard precautions and hygienic procedures. An assessment of the hospital’s supply of essential protection equipment (gloves, aprons etc.) should be done. If stocks are insufficient, the necessary materials and equipment must be provided. MSF could provide the necessary materials after reaching an agreement concerning their use. In order to assure a constant supply to the clinical areas, the logistics department should assess stock keeping and distribution procedures in the hospital. Advice should be given as required. 9.9.4 Cleaning and Disinfection Cleaning Good cleaning services are essential for infection control in hospitals. In order for good cleaning services to function, the following need to be ensured: An adequate water supply. Adequate materials (and protective clothing as appropriate). Training of the cleaning staff. The heads of each hospital service should be involved in ensuring the quality of cleaning in their service. A hygiene supervisor and committee should be appointed by the hospital to supervise cleaning and waste management. Hygiene Washed hands and sterilised medical devices can be re-contaminated by contact with surfaces due to incorrect cleaning/disinfection practices. Inadequate or incorrect cleaning and disinfection practices can lead to an increase in: Transmission to patients by direct/indirect contact through contaminated hands or medical devices. Dispersion of virus via hand or foot carriage after contact with incorrectly cleaned and disinfected surfaces. Corrosion of equipment due to incorrect use of cleaning products. Disinfection of Materials 109 Only disposable needles and instruments should be used. If re-usable items like surgical instruments are in use, then they must be properly sterilised. Disinfection of Facilities If, upon arrival of the team, the hospital is known to be a focus of infection, a thorough disinfection of all wards should be conducted. However, it may not be necessary to close the affected units or departments. A triage of the patients present should first be done to reduce the risk of recontamination of the premises. Patients could then be transferred into another ward while their room is disinfected. All floors, walls, surfaces, and items (beds, tables, chairs, etc.) must be sprayed with 0.5% chlorine solution. Mattresses should be rinsed with clean water. Portable material should be taken outside to dry in the sun after spraying. Patients can be transferred back into their ward the following day and disinfection can continue in other parts of the hospital. Patient transfer to the VHF Treatment Unit must be followed by room disinfection even if there is only a suspicion of VHF. In order to allow good disinfection, 0.5% and 0.05% chlorine solutions are necessary; MSF should help provide these. 9.9.5 Safe Linen Handling, Transport and Processing Hospital linen and patients’ laundry should not be taken out of the facility. Laundry and drying areas must be provided to avoid this practice. The disinfection teams according to established protocols must handle the linen that has been in contact with suspect VHF cases. The linen from hospital wards will be handed according to hospital policy. Caregivers must be trained by nursing staff in appropriate laundry practices (use of soap and water can be adequate). Drying on a clothesline in sunlight must be recommended. Staff doing the laundry must wear adequate PPE. Both machine and hand washing are acceptable if properly done. 9.9.6 Safe Working Practices a) Safe Handling and Disposal of Needles and Sharps This needs to be carefully taught, including such themes as not re-sheathing needles, only using single use needles, carrying sharps boxes to the area where the injection is done etc. It must be ensured that single use items are properly discarded and not re-used. b) Safe Management, Handling and Disposal of Other Medical Waste Safe and effective management of hospital waste is essential for preventing the spread of VHFs or other diseases. This is especially important for organic waste and sharps. Contaminated waste poses a risk to doctors and nurses; patients, visitors and families; people involved in the collection and disposal of waste (in many situations these are the people at most risk), and people living near to areas used for the unsafe disposal of waste. All health workers (both medical and non-medical staff) in contact with health care waste must be involved in its correct management and promotion: Medical staff are responsible for segregation according to the waste categories. Cleaners or ideally waste managers are responsible for collection. 110 One or two waste managers must be responsible for collection, storage, treatment, and final disposal. Safe waste management requires: A waste management area appropriate to the needs of the facility Adequate water supply and drainage Supply of personal protective equipment, and training in its use. Supply of waste material (puncture-proof containers, buckets, plastic bags, etc.) Identification of a team in charge of supervision of waste management procedures. Involvement of the chief of each department in the supervision of waste handling and disposal; and the correct use of PPE. Training staff in waste management procedures and standard precautions. The hospital should appoint a hygiene committee and supervisor to ensure safe and reliable waste management procedures. Heads of individual departments should be involved in the supervision and ensuring training in waste management procedures. c) The Collection and Disposal of Medical Waste Installing a temporary waste zone specifically for the hospital is a good option. It should allow for the disposal of the three types of waste (soft, organic and sharps). The waste zone should be in the hospital compound in a convenient location but out of the busiest traffic areas. Materials and equipment to allow segregation, safe collection, and transport of the waste to the waste zone must be provided: Sharps containers for needles, plastic bags for dry burnable waste and most organics. Discard organic waste such as placentas directly into a bucket containing 2cm of 0.5% chlorine solution, cover the waste with more chlorine solution. Disinfect the inside and outside of the bucket, cover and transport to the organic pit. Chlorine solution must be available in the waste zone to disinfect buckets, etc. Staff must be trained to manage the waste collection and disposal. Including: Safe handling and disposal of medical waste. Safe handling of blood/body fluid specimens. Safe removal of blood/body fluid spills. Safe personal habits and working practices. Specific precautions in obstetric care, in operating theatre, in laboratory. Precautions for cleaning and laundry staff. 9.10 Patient Placement Overcrowding should be avoided, with adequate spacing (2m) between beds and no more than one patient per bed. In order to avoid overcrowding, discharge procedures must be efficient; a daily discharge programme including weekends is advisable. 9.11 Visitor Access and Precautions for Patients’ Attendants Access to the hospital should be limited to hospital staff, patients, and attendants. Fence the hospital and position guards to organise and control the flow of visitors and attendants. Visitor access must be limited to as few as possible. One family member should be selected to provide care to the patient. This family member should be trained by the 111 nursing staff in the correct handling of the patient’s equipment (cups, plates, etc.) and in good laundry methods. Good hand washing practice must be taught to care givers. Family members must be supervised by the nursing staff to ensure safe practice. Water should be accessible to patients, staff, and visitors/caregivers. Water points, sanitary facilities, laundry areas must be available and easily accessible. It may be necessary to provide shelters for visitors and caregivers. 9.12 Medical Protocols and Reduction of Invasive Procedures Injections and unnecessary invasive procedures should be minimised in order to reduce risk; only critical procedures should be performed. However, this may be difficult to achieve as medical practices may be entrenched and populations may expect or demand injections. The objective of reducing such interventions must be agreed with local medical staff, as attempts to change practices may cause resentment and reduce co-operation in other areas. Revising existing medical protocols in collaboration with the local medical staff can help to improve the adoption of oral treatments. The intervention needs to have clear objectives, and in an epidemic, the objective within the hospital should be the control of infection. Activities implemented to achieve this objective, and the rationale must be clearly explained. 9.12.1 Surgery Specific measures may be taken to reduce the risk of transmission during surgical procedures including the use of reinforced gloves and blunt needles. These measures should be discussed with the surgical staff. Even if these measures are adopted, surgical procedures should be limited to life-saving situations. Use electric lancets. Do not use scissors, but only lancets, with a "hook". Wear additional, disposable protective sleeves, and change whenever they are contaminated with blood. Wear on the gown an additional disposable apron, and change whenever it is contaminated with blood. Use synthetic fibre gloves. Use blunt needles for sutures, as used for liver surgery. 9.12.2 Transfusion Preventing the spread of infection through transfusion may be difficult. There is a risk to both the patient to receive the blood, and to the laboratory staff handling the blood. The blood cannot be easily tested for Ebola or Marburg because: The results will not be available for a number of hours, by which time the patient may have died. The PCR tests (which are the best for this purpose) are not sensitive in asymptomatic patients and during the first three days of symptoms. The following measures are therefore recommended: Only life-saving transfusions should be attempted. Protocols should be discussed with the relevant hospital departments. The donors should be carefully screened; if they have fever or ANY symptoms or they are considered a contact they should not give blood. 112 9.12.3 Laboratory Services This is discussed in Section 9.15 Laboratory Services. 9.13 Water Supply Implementing standard precautions requires that an adequate quantity and quality of water is available. The quantities recommended in the “Minimum Requirements for Health Structures” should be adequate. Quantity Allow 40-60l per inpatient per day, and 5l per outpatient per day. Quality For preparation of chlorine solutions, the water should be clear. Turbidity should preferably be less than 5NTU. In case that turbidity is >20, water treatment should take place to reduce turbidity prior to chlorination. For disinfection of drinking water, residual free chlorine should be 0.3-0.5 mg/l at the tap. Storage Depending on the reliability of the water supply, an emergency buffer stock of water should be established (a 2-day supply is advisable), and/or prior arrangements made for immediate deliveries of water should the supply fail. Distribution Water is required in the hospital, distribution points should not be too far from the point of use to motivate the staff to prepare the chlorine solutions in the wards and to change/ refill them as needed. However, the existing system would have to be extremely poor to justify improving the system, or installing a new or temporary distribution system. 9.14 Peripheral Health Centres In order to avoid the transmission of Ebola or Marburg in health facilities and to the community it is necessary to implement Infection Control measures in the peripheral health centres. Government and private health centres may pose very different problems, and require different approaches and solutions. 9.14.1 Closure of Peripheral Health Centres The decision whether peripheral health centres should be closed depends on the importance of the service they provide and the degree of risk they may pose. It should be borne in mind that the closure of these services may cause people to seek treatment elsewhere, and they may go to places that are less safe or easy to control. Non-essential services in these centres may be stopped. The health authorities should be consulted about the possibility of limiting procedures like injections, small surgery, laboratory services, etc. If possible, these procedures should be limited to hospitals in order to avoid multiple points in the community where transmission risk is elevated. Assistance and interventions in private health facilities must be considered. The health authorities can order temporary closure if safe working practices cannot be guaranteed. However, an issue that may have to be taken into account is the financial ability of private health facilities to survive closure for more than a few days. 9.14.2 Infection Control in Peripheral Health Centres The health authorities must agree to support and be involved in any interventions in the peripheral health centres. 113 There may be a large number of health centres working in a given area, and they may be widely dispersed. Therefore, sufficient time and resources need to be devoted to addressing infection control improvements in these health structures. A nurse and a watsan should carry out an assessment of the health centres, and provide necessary advice and training on infection control procedures and health care waste management. If required, equipment such as sharps boxes, etc. can be provided. In every health centre, one person should be identified to be in charge of infection control. The peripheral health centres may be useful places for the dissemination of information about the disease and the outbreak. Information and resource material should be provided, as well as advice on how to deliver the information to the community. 9.14.3 Triage and Referral System It is important that good triage and a referral system to the VHF Treatment Unit be put in place for the detection and management of suspect cases. The referral system could link to the Alert teams (see Chapter 4: Epidemiology) or directly to ambulance teams for transfer to the hospital. The referral system must be supervised, by either WHO or MSF, or the government if able. If patient numbers are high, it may be difficult to implement a formal triage system like the one described for hospitals (using triage forms etc). If this type of formal system is possible, it should be put in place. If not, education should be provided to the health centre staff about the disease, the symptoms, and the importance of referral. The importance of not conducting invasive procedures on suspect patients should be emphasised. 9.14.4 Water and Sanitation To implement the changes in practices (hand washing, preparation and use of chlorine solutions, safe waste management, etc.) some assistance with basic infrastructure, materials, and equipment may be needed. It may be necessary to provide chlorine and water storage containers; the construction of a basic waste zone with facilities according to the needs should also be considered. 9.15 Laboratory Services This section covers all normal laboratory services, but it does not cover specialised VHF laboratories. Laboratory staff handling blood and other body fluids run the risk of exposure to VHFs. The risk varies with the sample being handled; for example, fixed malaria smears are thought to be safe, but whole blood is dangerous. Clearly, laboratory services are useful for the diagnosis of a wide range of conditions, and improve medical management. It may also be hard to re-train staff to work without a laboratory when the protocols used rely on laboratory tests. However, the value of laboratory services must be balanced against the risks to the staff, bearing in mind that many medical conditions can be adequately diagnosed and treated without relying on lab tests. If triage procedures are working well, the chance of blood being taken from VHF patients in the hospital is reduced. Therefore, laboratory services in hospitals may be safer than laboratories outside. Closing laboratories outside hospital, and in hospitals with poor 114 patient triage, should be considered. Special caution should be taken with haematology patients. Training on safety measures and waste disposal for the laboratory services should be considered. 9.16 Vaccination In a large epidemic, the safety of the normal vaccination program should be considered. The risk of transmission via these injections is generally less than that of therapeutic injections, as the people receiving the vaccine are not usually sick. However, there will always be some risk. If programs are well organised and staff work safely with gloves and single use needles, the risk is probably low. Good sharps boxes should be used, with proper disposal systems. Providing advice on safety and equipment may be required. Suspending the vaccination program can be considered, however if children are lost from vaccine programs they may never return to receive important injections. A catch up campaign for measles should be done once vaccination programmes are resumed. ! Vaccines should never be given to people who are unwell. 9.17 Traditional Healers and Birth Attendants Traditional healers and birth attendants are likely to be directly affected by VHF epidemics. They have often been described as being victims of the disease rather than implicated in the spread, although if they conduct invasive procedures there will be a risk of transmission. They must be included in the programme to improve infection control practices in the community. 9.17.1 Traditional Healers Traditional healers can be very important and respected people in the local community, and their treatments and ceremonies may be integral parts of the culture and belief systems. Although not always easy, it is important to try to reach the traditional healers and engage them in discussions about the outbreak and the disease. The risks of VHFs should be explained to them, and the fact that that the risks to them are probably greater than the risks to their patients. They should be encouraged to take precautions, like wearing gloves, and adopting safe practices. They should be advised not to work if they feel even slightly unwell. They should be encouraged to refer possible Ebola or Marburg patients to the alert system or the Treatment Unit. 9.17.2 Traditional Birth Attendants Traditional birth attendants are at risk during an epidemic due to their considerable exposure to body fluids. Pregnant women suffering from VHFs often abort or miscarry; therefore, there is a higher risk when attending these births than normal full term births. Likewise, there is an increased risk in attending to any woman who is ill or has fever. 115 Advice about the disease, the risks they are exposed to, safety procedures, waste management, and the use of basic equipment should be offered. They should be encouraged to use the alert system for patients who are unwell or have fever. They should be advised NEVER to attend births when they feel even slightly sick. Back to Table of Contents 116 10 Safe Burials, Disinfection, and Ambulance Services This section deals with the issues that must be considered and addressed when planning burial, ambulance and home disinfection activities. Primary audience: WHS and socio-cultural staff. Secondary audience: Coordinators. 10.1 Introduction Safe burials, home-disinfection and ambulance services are critical for the success of the outbreak control intervention. These activities must always be carefully considered when planning the intervention. It is essential to ensure that these activities are correctly implemented and performed safely. Correct implementation can reduce infection risks for those that are in close contact with patients and the deceased, family members and the local community. This section provides general information on how to perform burials, and organise ambulance transport and home-disinfections. These activities must always be designed and adapted to be appropriate to the local social and cultural context. Perceptions of sickness and infection/disinfection, along with local rituals and common behaviours related to burials and the management of dead bodies should be investigated. Information can be acquired through discussions with key persons, and (if possible and appropriate) observing a “normal” burial. Religious and medical organisations working in the area that have knowledge and understanding of these cultural issues can be a good source of information and guidance. They may also be able to advise on adapting safety and infection control measures to encourage acceptance by the population. All these activities require good training and strong supervision, and staff must have a sensitive and diplomatic approach. 10.2 Cultural and Social Factors Death, mourning, and funerals must always be addressed in a sensitive manner. Performing safe burials disrupts traditional procedures and essential social and cultural rituals; reluctance to change practices and possible hostility towards the teams performing safe burials can be expected. The families, relatives, and communities will be grieving, and they will be anxious and fearful. Tension and possible aggressive responses can be reduced by treating patients and dead bodies respectfully, while protecting both the relatives and the staff from the risk of contamination. Customs and traditions related to death can help the bereaved come to terms with their loss, for example pre-burial body washing; placing clothing and belongings of the deceased in the grave; taking pictures; grieving speeches, etc.. Where practicable, these traditions should not be prevented; rather the procedures for safe burial should be adapted to these traditions. Burials must always be done with maximum respect for the people and the culture. Keep in mind that accompanying sick family members through sickness, old age, and death is normal and an important process in most cultures. Basic Recommendations Identify local leaders and seek their support for implementing safe practices. 117 Respect tradition without compromising on safety. Implement all activities calmly and respectfully. Do not make activities more spectacular than necessary; adopt a “low-key” approach. 10.3 Involvement of Traditional and Community Leaders Liaise with the leaders of the neighbourhood, village, or community, and endeavour to gain their trust. They can act as mediators to obtain the agreement of a family to allow safe patient transport, burial, or home-disinfection. However: The traditional leaders may be put under significant pressure by the community or other authorities to resist any outside interference or changes to tradition. The outbreak control activities may not be their highest priority, and they will have other tasks and responsibilities. 10.4 Communication The burial, ambulance, or disinfection procedures, and the reasons for them, must be explained clearly to the family and to their neighbours. This can help to prevent misinterpretations that may lead to harmful rumours and stigmatisation of the victims and their families. Always take the opportunity to communicate with the family members and bystanders while preparing the patient for ambulance transport, during the burial procedures, and during household disinfection. These will often be highly emotional situations, it is therefore very important that a good rapport be established between the team and the concerned members of the community. The procedures must be explained to them and they must be given the opportunity to voice their concerns and receive a response. The burial, disinfection, or ambulance team may be too busy to do this, in which case they must be assisted by somebody with the necessary communication skills. 10.5 Security There is potentially a higher than normal security risk when carrying out mobile activities, especially conducting burials, household disinfections, and ambulance services. This is most likely to be an issue when there is mistrust and lack of confidence in the teams and the activities, but must also be considered in generally insecure areas. Previous incidents include stoning of burial and ambulance teams in Uige, the murder of health promoters in DRC, and the activities of the Lord’s Resistance Army in Gulu. The security coordinator must continuously monitor and assess the security situation. If there are unacceptable risks, then the mobile activities must be suspended. A close follow-up of the movements of the teams must be done by the MSF radio operator. Reliable communication has to be guaranteed at all times. Drivers must always remain on standby in the car attentively following the activities, and ensuring communications with both the mobile team leader and the radio operator. 118 10.6 Information Flow 10.6.1 Ambulance Service 10.6.2 Burials Daily follow up of all the activities must be done to facilitate reporting to other actors and to support the epidemiology teams. 10.7 Adapting Procedures See Annex 11.5 Example of Culturally Adapted Pre-Burial Body Washing. Many of the burial and disinfection activities are somewhat violent (disinfecting and preparing dead bodies for burial, destroying personal items during household disinfection, etc.). Clearly, there will be a tendency for families and communities to object to these measures. In order to avoid rejection of these activities by the population, the processes should be adapted to the social and cultural context. If the community rejects the activities, the physical safety of the teams may be put at risk; without a guarantee of security, the outreach activities cannot be done. 119 The mobile teams themselves can be a good source of information on local beliefs and behaviours, and any evolving changes they observe. This information should be used to adapt the protocols to be culturally acceptable, and so that the workers are confident and safe in performing their work. 10.7.1 Operational and Working Practices Teams who go to disinfect a house, transfer a patient or organize a burial must not arrive wearing full protective clothing. o The teams should go to the site wearing scrub suits and boots, and put on the remaining protective clothing before starting the work. o Arriving in normal clothes helps to normalise and humanise the process. o Team members should not start putting on the protective clothing until the procedures have been explained to the family and the neighbours. People should be able to see the faces of the workers; however if there is a risk of stigmatisation or social exclusion of the workers they may not be comfortable with this approach. Dressing and undressing procedures must be the same and will follow the same rationale as in the VHF Treatment Unit. The vehicles used for transport of bodies or for the ambulance service must be driven carefully and considerately. 10.7.2 Interaction with the Families All discussions with the families must be clear and transparent. All the procedures and activities must be explained to the patient and the family. People must understand what is being done to their dead or sick relative, and to their home. If possible and practical, people should have the opportunity to observe what is being done. The psychological support team should assist with all outreach activities. 10.7.3 Involvement of Families in Burials Family members must be invited to witness, and where possible take part in burials. o At least one representative of the family should attend the burial. If that is not possible, the family must be informed of the location of the grave. o Family members who wish to witness the operations or to accompany the patient during transfer must be dressed in protective gear. Traditional customs and practices should be encouraged as long as they can be done safely, for example, traditional body washing can be done if performed by trained staff; this should be done using chlorine solutions and absorbent pads. This procedure can be observed by the family. Allow the family members to view and identify the body before burial. o Family members must be sure that their relative has died, and that the body bag or coffin really contains that person. o The viewing of the body must be done safely and must be managed by trained staff in full protective clothing. Unsafe practices must not be allowed, for example the reopening of body bags or coffins for viewing and/or touching of the body by the mourners must be forbidden. 10.7.4 Safe and Acceptable Burials To facilitate the work of the burial team, the gravesite should not be too distant and it should be easily accessible. This will reduce transport time and consequently risks. If 120 possible, the graves of VHF patients should be prepared in a separate area from the other graves. Prepare individual graves. It is unlikely that mass graves would be necessary, or culturally acceptable. o A grave must be at least 2m deep with the bottom of it at least 1.5m above the ground water table. However, in high groundwater areas if it is not possible to achieve both criteria, then the 2m depth of the grave should be prioritised. A cross or other marker with the name of the deceased and date of death must be placed on the grave. Burials should be done using culturally acceptable “containers”, for example coffins, shrouds, etc. o The body must be sealed in a body bag, and the coffin must be disinfected. o To facilitate this process, coffins and shrouds must be available and offered to the families. The actual burials can be done wearing scrub suits and gloves if the coffins are water tight and well sealed, and the procedures to handle the body, body bags, and coffins are strictly followed. 10.7.5 Household Disinfection The prompt, thorough disinfection of the home of an Ebola or Marburg case is extremely important, not only for safety reasons but also to reassure the family and neighbours that the home does not pose a danger to them. The disinfection of houses requires the destruction of some household items and personal belongings of the patients. This can be difficult for the families to bear, both mentally and economically. To ease the acceptance of this process some of the items that are destroyed during the disinfection should be replaced. Provide Solidarity Kits that help the family to overcome the consequences of the disinfection. See Annex 11.6 for practical guidance on Procedure for House Disinfection. 10.8 Logistics The bio-safety material is the same as used in the Treatment Unit. See Annex 11 Ambulance and Burial Services for guidance and checklists of material for disinfection, ambulance, and burial activities. If high quality body bags are available, it may be possible to do burials with minimal protection. 10.8.1 Ambulance and Burial Teams It is important to keep at least one stretcher clean (disinfected) and available at all times in the vehicles. Steps can be installed at the rear of the pickup for patients able to move by them selves. Coffins (or other acceptable safe containers) should be provided for families who cannot afford them, or if there are time constraints in the normal supply. Transport The number of vehicles required will depend on the scale of the epidemic. However, a minimum of two pickups should be available to allow disinfection and burial or ambulance teams to carry out their task independently. In order to provide privacy for both patients and coffins, the pickups should be covered. 121 The cars must have radio communication equipment. All vehicles must have a hand sprayer with 0.5% chlorine solution, and this must be refreshed daily. In order to facilitate locating patient’s houses, vehicles should be equipped with a GPS device. When staff are fully dressed up they must not enter the cab of the pick up. The driver should not leave the car. 10.9 Human Resources The number of mobile teams required will depend on the scale of the epidemic. In a small outbreak, one team may be sufficient: one team can manage 2 to 3 ambulance, disinfection, or burial procedures in one day. However, having two teams allows more flexibility and helps in reducing the waiting time for a patient or body. At the beginning of the intervention, it is better to have too many workers than too few. Each disinfection, ambulance, and burial team should be composed of five people: 1 driver 1 expatriate watsan or supervisor 1 or 2 sprayers 1 or 2 helpers The team can be complemented by a communicator (psychologist or other) and a logistician in case of tense security situations. It may be necessary to have a female staff member accompany the ambulance team when transporting a pregnant woman; it can be seen as offensive if men are involved in touching her. The mobile teams often face difficult and stressful situations, therefore if appropriate, prepare emotional debriefings for the teams with the support of a psychologist. 10.9.1 Training Mobile team workers must receive training on: General knowledge on the disease, contamination routes, etc. The risks that they will face: physical and social. Dressing and undressing protocols. The rationale must be fully understood. Protocol for safe transportation of patients. Disinfection procedures. Safe burial procedures. The reasons for strict burial and disinfection procedures. See Annex 15 Job Profiles and Task Descriptions Back to Table of Contents 122 11 Socio-cultural Issues and Health Promotion This section deals with the anthropological, social, and cultural issues that influence an Ebola or Marburg outbreak control intervention. It describes the information that should be collected and analysed in order to design and adapt intervention activities so that they are acceptable to the communities, and to identify and design appropriate messages in the different phases of an intervention. Primary audience: Health Promoters, Psychologists. Secondary audience: Medical and non-medical staff, Coordinators. 11.1 Introduction In an outbreak situation, social, cultural, and anthropological (SCA) issues can play a huge role in the success or failure of the control efforts. A good understanding of the most important factors is extremely useful, for not only the formulation of health promotion messages and behaviour change efforts, but also to ensure that other aspects of the intervention can be made appropriate to the context. It will not be possible to carry out a full study of the SCA context. However, it is probable that anthropological studies have been done in the area, and these studies and their authors can be a good starting point for background info. A two-phased approach should be adopted: an initial rapid dissemination of information to the affected communities, followed by more targeted messages and activities specific to the cultural, social and anthropological context. In order to select and design the 1st phase messages, an initial assessment of social and cultural issues should be done, but due to time constraints this will be limited, and should focus on acquiring information from focus groups and key informants, including health staff, local leaders, religious leaders, traditional healers and birth attendants, and patients’ families. It is clear that in the initial phase, the messages and the method(s) of delivery are unlikely to be completely appropriate to the context. Nonetheless, it is important to ensure that the approach is relevant and acceptable to the target audiences, so as not to adversely affect the 2nd phase activities. The team should refer to the MSF lessons learnt publications as they highlight universal messages and methods that should be considered when conducting outbreak control interventions. The information collected and analysed in this 1 st phase is also useful for designing other aspects of the intervention. Furthermore, it will assist in identifying issues that require further investigation and attention in the 2nd phase. 11.2 First Phase 11.2.1 Collection of Information The information collected in the 1st phase can be limited to local beliefs and practices related to known risk factors. Consumption of bush meat. Funerals and mourning activities (e.g. washing with, or drinking the water used for preparation of the corpse.) Care for the sick by family members. Attitudes to what is considered “dirty” in relation to body fluids, excreta, vomit, sweat, saliva, blood, etc. Any particularities, e.g. babies, children, relatives, invalids, etc. 123 11.2.2 Dissemination of Information It is essential to provide information to the affected communities as quickly as possible. The planning and organisation for the dissemination of information and messages concerning the disease and the outbreak control intervention should be started on the very first day. One person should be in charge of this from the beginning of the outbreak. Messages and methods used in previous outbreaks can be adapted and utilised. It is essential to try to reach as many people as possible as quickly as possible. Therefore, a mass media approach should be adopted; this can include the utilisation of radio and television, newspapers, posters, leaflets, mobile loudspeaker announcements, etc. A more targeted approach can be adopted for specific groups such as hospital staff, local leaders, informal health providers, etc. 11.3 Examples of Content for 1st Phase Messages Simplicity is crucial! 11.3.1 First Phase Operational Messages It is important that the community understands what MSF and the other actors are planning to do in order to care for patients, and to control the outbreak. The rather bizarre and extreme measures must be explained, especially the strange suits and the need to isolate patients, and the reasons why they are necessary. Figure 8 - Initial Phase Operational Messages MSF is a humanitarian, medical relief organisation with experience working in Ebola and Marburg outbreaks in Uganda, DRC, Angola, etc. MSF is working with the health authorities to control the spread of the disease. MSF will set up a special Treatment Unit for Ebola/Marburg patients at location. MSF will provide medical care and treatment to the patients at the Treatment Unit. Ebola/Marburg is very serious and easily transmitted; therefore, the way of working is different to other diseases, using special protection suits, strict methods for managing hygiene and waste, and housing patients in separated wards. Adapt according to the context. Include WHO, and other organisations working on the outbreak. 11.3.2 First Phase Disease Messages Messages should be simple, concise, and reassuring. They should include the fact that there is an outbreak, basic information on the disease and transmission methods, and information on how to protect oneself, and what to do if someone suspects they have caught it. Figure 9 - Initial Phase Disease Messages There is Ebola/Marburg disease in location. It is a very serious disease and makes people very sick. People who are sick with Ebola/Marburg will have headache, fever, weakness, joint and muscle pain, diarrhoea, vomiting, etc. Anybody who has the disease, or who thinks they have the disease must go to the location. o A doctor will examine you. o A test will be done (depending). o You will be cared for if you have the disease. 124 Protect yourself and your family: o Do not touch or eat animals from the forest. o Do not touch a person who is sick with Ebola/Marburg. o Do not touch the body of a person who has died from Ebola/Marburg. o Do not touch the body fluids of a sick person. o etc Adapt according to the context. 11.4 Second Phase – In-depth Cultural & Social Information and Analysis The 2nd phase information gathering and messages should focus on issues that were highlighted during the 1st phase or that have been identified as being particularly delicate or problematic. A summary of topics that could require further investigation is listed below. See annex 3.1 Rapid Assessment Checklist. Awareness of 1st phase activities: o Views and opinions on the activities. o Relevance of messages. Investigation of any previous filovirus outbreaks in the area: o How was the outbreak managed? o How did the population respond to the outbreak? Investigation and analysis of cultural, social and anthropological factors: o Different ethnic, religious, kinship groups, and the interplay and interaction of different groupings. o Different age, gender, etc. issues within and between groups. o Power structures, traditional leaders, opinion leaders, etc. Investigation and analysis of disease explanation models: o What are the terms that people use for illness? o How do they believe illness in general is caused? o Do they believe in contagion as a source of illness? o What are the local beliefs with regard to touching both the well and the sick? o What are the terms for “clean”, “unclean”, “safe”, and “unsafe”? o Are excreta, blood, or other body fluids viewed as “unclean” or “unsafe”? o What are the traditional responses and taboos associated with illness? o Are there instances where isolation or limited contact with the sick is practiced? Beliefs and knowledge about Ebola or Marburg: o Have they seen this disease or something similar before? o If so, what happened? o How do people refer to and name the current disease? o How do people explain the disease? Is it perceived as abnormal? o How do they think that the current illness is caused? o What are the signs and symptoms of the disease? o What is the likely outcome of the disease? o What are considered appropriate treatments for this disease? o What can be done to prevent this disease? Are there traditional isolation or quarantine methods used for this disease. Traditional and religious beliefs related to death: o What are the beliefs related to death? o Is there a difference between traditional beliefs and religious beliefs? o Are there any significant conflicts between the two sets of beliefs? What is involved in a proper traditional burial? 125 o How is it done and who is normally involved? o How are condolences conveyed to the bereaved? Beliefs, perceptions and rumours relative to MSF and other outbreak control agencies. Has the community had previous experience with outside help for health matters? o How has outside assistance been perceived in the past? o What were the responses to this assistance? What are the likely barriers to changing behaviour? 11.4.1 Tools for Data Collection and Analysis Observation. Question checklists. Key informant interviews. Focus group discussions. 11.5 Changing Risk Behaviours Encouraging people to change their behaviour is never easy. However, if the community has confidence in the intervention and its methods, the overwhelming fear of the disease can motivate people to accept the messages and adopt a change in behaviour; at least for the duration of the epidemic. Conversely, a similar situation can result in a rejection of the messages; if the fear and uncertainty are so great, people may prefer to “stick with what they know”. In order to learn from the experiences of past outbreak control teams, the MSF team should refer to the MSF publications concerning lessons learned in the hospital, and lessons learnt in the community Changing risk behaviours by simply prohibiting risky behaviours is unlikely to be very successful; it would be difficult to enforce and would probably create resentment and rejection of the message. Encouraging people to change their behaviour and adopt safer practices is often a lengthy process involving a number of stages. A model used in more conventional health promotion activities and studies is given below. It illustrates these stages of change, and possible measures to facilitate progress on to the next stage. Pre-contemplation: individual has a problem (whether he/she recognises it or not) and has no intention of changing. o Provide information and knowledge. o Propose alternative behaviour. Contemplation: Individual recognises the problem and considers changing. o Facilitate reflection and re-evaluation of the issue. o Encourage adoption of alternative behaviour. Preparation for Action: Individual intends to change the behaviour. o Facilitate and enable alternative behaviour. Action: Individual changes behaviour. o Reinforcement of messages. o Continue enabling of new behaviour. Maintenance: Individual maintains new behaviour over a period of time (6 months). This model is most applicable to long-term health behaviour change, but it can be assumed that a similar accelerated process would take place in an emergency outbreak situation. 126 Appropriate information and health promotion activities should reach all members of the affected communities. Furthermore, specific activities should be implemented to target those people who are most at risk, including health staff, patients’ families, traditional healers, and birth attendants. Where possible, positive messages stressing alternatives and options should be utilised, these alternatives should be enabled, and facilitated if appropriate, e.g. providing traditional healers with soap, gloves, etc. MSF should encourage innocuous practices and behaviours that increase the community’s involvement in the control of the outbreak. For example, family members should be given the opportunity to perform song and dance during burial activities, and viewing the body and/or face of the deceased by at least one designated family member should be facilitated. Back to Table of Contents 127 12 Psychological and Social Support This section describes the psychological and social issues that can arise, and the possible consequences for the persons affected, and the outbreak control activities. It suggests approaches for dealing with these issues and the type of support that could be provided to the patients, relatives, staff, and the community. Primary audience: Psychologists. Secondary audience: Mobile Team Coordinators. This type of outbreak can cause a variety of emotional impacts. Psychological and social support should be provided for patients, their families, the community, and health staff. This support should be offered from the outset of the intervention. To be relevant, the support and the approach have to be tailored to the social and cultural context. The sociocultural and anthropological analysis described earlier for the health promotion/social mobilisation activities will be helpful in designing these support activities. See Chapter 11 Socio-cultural Issues and Health Promotion. The provision of psychosocial support can help in demonstrating the caring aspect of the intervention. This may also encourage more openness and a better reception by the community of the health messages, and to adopting changes in behaviour. It is important to include material support in this approach. The home disinfection can result in many families losing important belongings, including bedding, furnishings, clothing, etc. It is advised that a basic kit of household items be provided to affected families. This can include a mattress or mat; bedding; basic clothing; cooking and eating utensils; and cleaning materials. Provision of food should also be considered for the survivors; they will be unable to work during their convalescence. Psychosocial Component The fear induced by the outbreak, its evolution, and the control measures may cause intense destabilization in the community and within ongoing MSF operations. To counter or prevent this fear, targeted information should be provided to the community, MSF staff and other counterparts in order to improve understanding of the disease and to encourage acceptance of the activities. Mental health and psychosocial activities should be an integral part of the following components: Watsan activities. The Treatment Unit. Home Based Support and Risk Reduction. Psychosocial kit distribution & psychological follow-up. Health promotion and community mobilisation. 12.1 Main Objectives To support affected families by reducing the impact of stress, fear and stigma. To facilitate the psychological process for families throughout the various stages: identification, hospitalisation, notification of death, burial, and bereavement. To improve the quality of care for the patient and the family in collaboration with other team members. 128 To facilitate an understanding of the disease within the community and encourage acceptance of the outbreak control activities. To support staff working in the hospital and the Treatment Unit. 12.2 Mental Health and Psychosocial Activities 12.2.1 VHF Treatment Unit and the Hospital Objectives To facilitate the psychological process for families throughout the various stages: identification, hospitalisation, notification of death, burial, and bereavement. To reduce anxiety and fear in order to improve collaboration with the beneficiaries. To improve the quality of care for the patient and the family in collaboration with other team members. A psychologist and a socio-cultural mediator carry out the mental health activities within the hospital. If the Treatment Unit is set up in the hospital, it is important to consider hospital personnel from the beginning. Informing them and making them participants in order to facilitate collaboration and the assumption of responsibility in the control of the epidemic. Admission Provide information about the disease and transmission; infection control procedures; care provided for the patient in the Treatment Unit; visiting rules, MSF activities; etc. Provide initial psychological care for patients and their relatives. Hospitalisation Give test results to the patient and relatives, and explain what the results mean. Inform families that their homes will be disinfected, and explain how this will be done. Arrange distribution of the psychosocial kit. Inform the relatives about the medical evolution of the patient. Provide psychological support for patients: o Provide counselling for patients. o Ensure decent inpatient living conditions together with medical staff. o Preserve the dignity of the patient: alleviating suffering; arranging family visits; decorating rooms, etc. Provide psychological support for relatives: o Provide counselling for relatives. o Arrange for the family to be close to the patient at the time of his/her death. o To support the family in this process. Discharge Accompany the patient to his/her home. Explain to neighbours about the patient’s recovery in order to prevent or reduce potential social stigmatisation (rejection, death threats, aggression, destruction of personal belongings, etc.) Ensure a schedule of home visits for psychological follow-up. Death Notify relatives in the event of the death of the patient. Facilitate and assist in the bereavement process. Provide support in arranging the burial taking account of the safety precautions. 129 Other Recommendations Regarding the VHF Treatment Unit Ensure persons who are inside the Unit can communicate easily with those outside. Set up an appropriate space to provide psychological care to patients and their families. As soon as entry to the Unit is safe, the psychologist should enter the wards in order to: o Provide psychological support to the patient. o Accompany, and support the families who are fearful of entering the Unit. Ensure reliable lighting is organised for the wards; this can improve safety, and makes life easier for the patients and can help reduce their fears. Provide radios within the wards; this can help the patients feel less isolated for the length of their stay. 12.2.2 Home Based Support and Risk Reduction Objectives To reduce anxiety and fear in order to have better collaboration with beneficiaries and promote acceptance of the HBSRR service. To facilitate an understanding of the disease and promote acceptance of outbreak control activities within the community. To improve the quality of care for the patient and the family in collaboration with other team members. A psychologist and a socio-cultural mediator provide psychological follow-up together. A trained socio-cultural mediator could eventually carry this out alone. HBSRR Assist the family in selecting a caregiver. Provide psychological support to the family while there is a patient in the house. Explain the benefits, and offer the patient admission to the VHF Treatment Unit. Provide information about the disease, infection control procedures, and the HBSRR programme to neighbours and the community. Patient Transfer to the Treatment Unit Provide explanations to the neighbours about the treatment and the eventual recovery of the patient in order to prevent or reduce possible social stigmatisation. Burial Ensure that the family is fully involved in preparation for the burial. Ensure respect for traditions (songs, dances, timing of ceremony, etc.) without compromising safety. Allow relatives to view the body and to give personal belongings to be placed in the coffin. House Disinfection Support the disinfection team. Before starting the disinfection activities, the psychosocial team members provide information to the community and explain the reasons for disinfection. Provide emotional support and information to families during house disinfection procedures. 130 Identify one relative to assist the disinfection team in order to reduce rumours and facilitate understanding and acceptance. The Community Facilitate an understanding of the disease within the community, and encourage acceptance of MSF activities. Improve the quality of care and support for the patient and the family in collaboration with other team members. Assist beneficiaries in the understanding and acceptance of safe burials, house disinfection, and transfer of the patient to hospital. 12.2.3 Distribution of the Solidarity Kit Objectives To ensure psychological follow-up. To facilitate the contact tracing activities. To monitor the impact of outbreak control activities within the community. See Annex 10.2 Distribution of Solidarity Kit. 12.2.4 Health Promotion/Social Mobilisation This should be managed and performed by a health promotion professional or anthropologist with the assistance of a Socio-cultural Mediator. Knowledge and understanding of the anthropological, social, and cultural context is indispensable. This is explained more fully in Chapter 11Socio-cultural Issues and Health Promotion. Objectives To provide information about the disease and the outbreak, to facilitate understanding within the community and encourage acceptance of outbreak control activities o To train staff of other organisations involved in outbreak control activities (NGOs, public institutions, etc). o To organise information and education sessions with key persons (community leaders, traditional healers, etc.). o To put a health promotion and social mobilisation network into place. Back to Table of Contents 131 13 Logistics This section deals with particular logistical issues that are not covered elsewhere in the document, including the set-up of facilities, housing, emergency stocks, and the VHF kits. Primary audience: Logistics Coordinators and Logistics staff. Secondary audience: Outbreak Control Coordinators. Good logistical support is crucial for the set up and smooth running of the programme. Without good logistical support the intervention is likely to be disrupted and delayed, or may even fail. There is important logistical input required in all aspects and activities of the intervention. Logistic components will be similar for all outbreaks, but actual needs will depend on the size and the particularities of the outbreak. Specific logistical information and requirements can be found in each section of this document. 13.1 Emergency Preparedness Keeping a complete standard MSF Viral Haemorrhagic Fever Kit on standby in the field could be useful in very high-risk areas. If this is to be considered, the kit should be stored in a regional centre with good communication routes to neighbouring countries. This should be co-ordinated internationally between the MSF-sections. Human outbreaks occur very sporadically and irregularly, so this can result in a very expensive collection of materials sitting idle for months and/or years. Some of the kit contents will expire or degrade with lengthy storage especially when stored in tropical conditions, therefore all of the kit items should be regularly checked, and items replaced as required. Alternatively, a more practical option would be to have only the Sampling & Assessment Module (module 7) of the kit available in the field for identification of possible outbreaks. If a positive case is confirmed and MSF decides to intervene then the complete VHF Kit can be ordered. 13.2 General Logistic Support 13.2.1 Epidemiology and Surveillance Coordination Base This is where the epidemiological information is centralised, and from where the mobileteams will be coordinated. Requirements Central location, and easily accessible. Secure with sufficient space for computer equipment, communication systems, and coordination meetings. Reliable power system. Well functioning communication base. Appropriate communication equipment. Smooth information flow (forms, protocols). 13.2.2 Mobile Surveillance Teams These are the teams doing active case finding, contact tracing, social mobilisation, and education. Requirements Depending on the size and accessibility of their working area, they will need: Transport – this can be anything from cars to bicycles. Communications - those working in distant places must be able to communicate with the base. 132 13.2.3 Ambulance Teams & Burial Teams Requirements Transport o Depending on circumstances one vehicle could be used for both burial and ambulance activities, however it may be necessary to have two vehicles, one being used only for burials, and the other used only for transport of patients. Consider using different coloured vehicles for burial and ambulance. In large outbreaks, more vehicles will be required. o Preferably, pick-ups or ambulance with separated cab. The patient area must be easy to clean and disinfect. Ambulance and burial vehicles should preferably be equipped with communication equipment, and a GPS. The driver must be the only person to use this equipment, and he must know how to operate the equipment. It may be necessary to consider the use of air-conditioned vehicles, as the driver is required to stay inside the cab while the teams are working without having the windows wide open. All necessarily protection material as listed in the checklists. See Annex 11.2 Checklist: Supplies for Burial Teams, and Annex 11.1 Checklist: Supplies for Ambulance Teams 13.3 Treatment Unit(s) The logistical needs for the set-up and running of the Treatment Unit will depend on the situation on the ground; requirements can be defined following the assessment and site planning. Specific requirements and recommendations are detailed in the appropriate parts of the document. This section deals with topics that are not covered elsewhere. 13.3.1 Estimates of Materials for a 10 Bed Unit & Associated Activities Disposable Protection Material High-risk examination gloves Household gloves Surgical gloves Disposable overalls/gowns Disposable masks Disposable caps (head covers) Diverse Consumables Garbage bags Absorbent pads (60x60 cm) Water HTH 70% Body bags Reusable Material Scrub suits Boots Aprons Goggles Sprayers 12 litres Sprayers 1 litre Consumption/day 180 pairs 35 pairs 50 pairs 100 120 120 Consumption/day 30 50 3 to 4m3 7kg Quantity will depend on several factors such as virus strain‚CFR, etc. Requirements / 10days 90 45 pairs 45 120 pairs 4 10 133 For a calculation sheet to assist in estimating PPE requirements, see Protection Material Calculations.xls on the CD. For quality requirements, see Annex 18 Quality and Requirements for Protective Equipment. 13.3.2 Security Stocks A spacious, secure, weatherproof storage is essential for the large volumes of materials that are required. Maintaining adequate security stocks is essential. Running out of just one of the protection items such as gowns or masks will result in stopping patient care and other activities. Ensure reliable and timely supply of all necessary equipment and materials. While calculating buffer stocks, take into account: The contents of the MSF standard VHF kit. Most of the protection material is specific and not MSF-standard. Non-standard orders can have longer delays than for standard items. Check with Transfer and/or logistic department for advice while establishing buffer stocks. The size of the buffer stock will depend on supply lines and availability, both at the local level and internationally. Take account of possible delays at all levels (international, national, customs, transport etc). Is the intervention part of a larger outbreak? Is there a centrally organised supply stock? Are MOH and other intervening actors also supplying equipment and material? Co-ordinate with them. Take account of contingency plans. Ensure there is sufficient material in case the isolation has to be extended, or other sub-outbreaks occur. 13.3.3 Patient Items Most of the necessary items are included in the standard MSF VHF Kit. It should be possible to purchase the items locally except perhaps the mattress covers and the absorbent pads. This is an example of a list of materials that must be available and ready at every patient’s bed at admission. Item Description Quantity 1 Mattress covered with heavy-duty plastic sheeting or PVC mattress cover. 1 2 Bed sheet and/or blanket. 1 3 Large blue plastic bucket for bathing. 1 4 Yellow bucket with lid for collecting liquid waste (vomit, etc.). 1 5 Green bucket with lid for the laundry. 1 6 Plastic plate. 1 7 Spoon. 1 8 Large plastic cup for drinking. 1 9 Jerry can of 5l for drinking water or ORS. 1 134 10 Bar of soap. 1 11 Roll of paper towelling. 1 Additional items for confirmed patients 12 13 Absorbent pads on bed in case of uncontrolled diarrhoea. Plastic bag suspended on end of the bed (to collect empty IV fluid bags as a record of IV fluid intake). 4 1 13.3.4 Kitchen and Food for Patients & Attendants The best way to provide food for the patients and possible attendants is to have a kitchen outside the Treatment Unit; this can be the central hospital kitchen or a specific kitchen for the Unit. Food is transported to the isolation unit and transferred from the kitchen cooking pots or containers at a defined location at the fence of the unit. The kitchen pots do not enter the Unit, and the Treatment Unit pots do not leave the Unit. There must be no contact between the kitchen pots and the Unit pots; nevertheless, the kitchen pots must be sprayed before returning to the kitchen. 13.4 Expatriate Housing Additional to the standard rules and recommendations for expatriate housing and hygiene, some extra measures are required in a VHF outbreak. Accommodation must be of a decent standard. Everybody needs to be able to rest properly, but this is particularly true for people working on high-risk activities, and adequate sleeping facilities must be arranged. Where possible, accommodation should be located close to the hospital and it should be convenient to allow staff to return for food and rest during the day. Two meals per day must be prepared. Bathing and shower facilities must be of a decent standard and have a constant, reliable supply of water. In malaria risk areas, it is compulsory to have mosquito nets installed and used, and mosquito repellent must be available for all expatriates. A hand washing station with 0.05% chlorine must be available at the entrance to the house. There must also be sufficient 0.05% chlorine solution available for disinfecting potentially contaminated clothing or other items of the team. Rodents, bats, flies, and mosquitoes must be controlled in the house. Beer and soft drinks bottles and cans should be disinfected before opening. Domestic hygiene is very important. Cleanliness of the house, and hygiene in food storage, preparation etc is crucial. 13.5 MSF Cars & VHFs There is likely to be significant damage to vehicles, as the disinfection process with strong chlorine solutions will cause rapid corrosion of the bodywork. This should be considered when designating vehicles for specific purposes. MSF-cars used for normal transport purposes must not be used as ambulances, or for the transportation of bodies. A car assigned as an ambulance or funeral car is used for this purpose only, and NOT for regular transport. In case of emergency, each regular MSF-car must have on board the following items. Quantity Description Remark 135 1 1 Contents of Mini-Kits 2 Sprayer (1litre) with 0.5% solution for disinfection. Sprayer (1litre) with 0.05% solution for hand washing. Mini-kits of full protective gear, in case of emergency. Quantity Description 1 Apron. 1 Pair goggles. 1 Tyvek suit. 2 Masks 2 Pairs latex gloves 1 Pair household gloves 1 Head cover 1 Pair shoe covers 2 Rubbish bags Must be replenished on a daily basis. Must be checked daily, and replenished as required. 13.6 The Kits: Composition, Use, and Logic behind Them 13.6.1 Health Centre Kit (locally composed). This kit is distributed to the Peripheral Health Care facilities. Before distribution, training must be given, and health centre workers must understand the safety protocols for dealing with suspect cases. The provision of protective equipment without training can be very dangerous if wrongly used, and it can give health care workers a false sense of security, and encourage them to attempt unsafe procedures. For composition of the kit, see Annex 17.2 Health Centre Kit. 13.6.2 Assessment Kit (locally composed). This is a rapid field assessment kit. It has been used to assess confirmed sub-outbreaks. It can be used to set up a small treatment facility, and allows the isolation and treatment of 2 to 3 patients for 3 days, while assessing the situation and initiating more orders according to the needs. For composition of the kit, see Annex 17.1 Assessment Kit – Locally Composed. 13.6.3 MSF Standard VHF Kit This kit is designed to allow the set up of a Treatment Unit of 10 beds and to run it for 10 days. It contains all materials, protective equipment, and drugs necessary to run the Unit, as well as associated outbreak control measures, including burial and ambulance teams and medical outreach. The kit is on stand by in Brussels (Transfer), it is not necessary to keep this complete kit in the field for preparedness. A good option for preparedness in risk areas would be to have available the Sampling & Assessment Module (module 7) of the kit for identification of possible outbreaks. The complete MSF VHF Kit can then be ordered if isolation facilities are to be set up after confirmation and the decision to intervene. The Kit consists of seven modules: For a detailed list of the articles in each module of the kit, see Annex 17 Contents of Viral Haemorrhagic Fever Kit. 136 Module 1 & 1b: Module 2: Module 3: Module 4: Module 5: Module 6: Module 7: Drugs. Medical material. Protection material. Logistic & Sanitation. Sampling6. Library, Forms, and Stationery. Sampling & Assessment7. 13.6.4 Module 7 (Sampling & Assessment) It can be useful to have this module on standby in risk countries with many reports of suspected outbreaks, where it can be used for assessment and confirmation of possible outbreaks. This module can be ordered separately. The module, allows a team to safely visit a site; assess a rumour of suspicion of Ebola or Marburg; and safely take, pack and transport samples. It includes all the necessary sampling, protection & disinfection material for two sample takers, and some extra protective material to install a small holding facility. 13.6.5 Local Purchase The VHF Kit is sent from Europe to set up a Treatment Unit and begin work. Further material can be ordered in bulk afterwards. If material is locally available, care is necessary to ensure that the quality meets the required specifications, especially for the protective material. For more information on quality requirements of protective material, see Annex 18 Quality and Requirements for Protective Equipment. Back to Table of Contents 6 Module 5 only contains sampling material to take and transport samples. There is no extra material, protective equipment or disinfectants. 7 Module 7 contains all necessary sampling material plus protective equipment, disinfection and other materials. 137 14 Human Resources This section covers specific HR issues that must be considered in an Ebola or Marburg outbreak. It covers staffing needs, health, job descriptions, and stress issues. Primary audience: Outbreak Control Coordinators, Human Resource Managers and Administrators, Psychologists. Secondary audience: All persons working on Outbreak Control Activities. 14.1 Expatriate Staff 14.1.1 Large Interventions The MSF expatriate team package recommended is: Coordination team: o Emergency, Medical, Logistics, Watsan, and Financial coordinators. Medical team. Watsan and Logistics team. Epidemiologist. Psychologist. Sociologist/medical anthropologist. Press-information officer. 14.1.2 Small Interventions Where the outbreak is small, and there is the possibility for support from an in-country coordination team, the package can be reduced to the following: Emergency/medical coordinator. Medical team. Watsan and logistics team. Sociologist/medical anthropologist. 14.1.3 International Coordination of Expatriate Staff There is often more than one MSF section working in a country. It is necessary to have a pragmatic approach to deciding how to share the intervention responsibilities. Good international coordination between the sections at field, capital, and headquarters level is very important. One key aspect of this coordination is facilitating flexible sharing of human resources both internationally and in the field. 14.2 National Staff Job Descriptions & Protocols According To Function See Annex 15Job Profiles and Task Descriptions 14.2.1 Recruitment Finding people who are willing and able to work on outbreak control activities can be problematic due to fear, stigmatisation, and the mystification of the disease. Most people will be extremely scared of becoming infected, and will require training, encouragement and support 14.2.2 One Well Defined Team It is important to have one well-defined team for the Treatment Unit, and not to have a rotation with, for example, the whole hospital staff. Safety is improved when everybody can become accustomed to the PPE, to the procedures, and to carrying out the various tasks. In addition, with time, a real sense of camaraderie can grow within the team, and 138 this can be helpful. Having one defined team also minimises the total number of staff exposed. 14.2.3 Training, Safety & Supervision A general training on the history, occurrence, transmission, treatment, barrier nursing, and dangers should be given prior to hiring staff. After this training, people have the choice to be deployed or not. When recruited, a more specific training has to be given, according to the job description. Safety of staff is a top priority. Staff must understand all procedures and safety regulations before entering the Unit. It is very important to have a regular and continuous supervision of all the staff. See annexes for examples of training modules. Annex 14.1 Example of Training Module for VHF Treatment Unit Personnel. Annex 14.2 Example of Training Module for Health Centres. 14.2.4 Life Insurance In case of death of a member of the national staff, the MoH may institute a system of compensation for the family. If such a system is not in place, the MoH should be encouraged to introduce one. 14.3 Shifts & Breaks Shifts should be arranged to allow staff to have sufficient time between shifts to rest properly. At least one break during a shift should be mandatory. The length and arrangement of shifts will depend upon the workload and number of staff available. When determining the number of breaks necessary during a shift, workload is important, as well as the climate: excessive heat and humidity when wearing the protective equipment can be exhausting, and this must be considered. 14.4 Staffing Needs for a 10bed / 50bed Treatment Unit An approximation of the number of staff necessary is shown in the table below. Actual staffing needs will depend on circumstances, and numbers should be adjusted accordingly. 10 beds Staff 50 beds Day Night Day Night 1 - 1-2 On call 1-2 - 2 1 1 On call 2 1 4 2 12 4 0-1 - 1-2 - 1 On call 1 On call 4 - 8 - 4 - 8 - Expat doctor Expat nurse National doctor National nurses Communication officer Expat watsan Safety officer Ambulance teams (4 per team) Burial teams (4 per Remarks Experienced staff useful when setting up. Consider need for 2 or more doctors to provide 24hr care. Experienced staff useful when setting up. Consider the need to provide 24hr care (as above) Presence may improve communication and acceptance with wider community. Minimum 4 per shift required working in groups of 2. Should be trained by a psychologist. In small units, work can be done by nursing staff. Consider need for psychologist in large units. Experienced staff needed when setting up. Experience useful - responsible for all safety issues. 139 team) Guard / spray man 2 1 4 2 1 1 1 1 Chlorine prep. 1 - 2 - Laundry 2 - 4 - Waste worker 1 - 2 - High-risk cleaner 2-3 1-2 4-6 1-2 Low-risk cleaner 1 - 2 - Sluice controller Should be people with confidence and leadership capacity. 14.5 Expatriate Life Living conditions need to be optimal as they have a direct impact on the level of tiredness and the stress of the team. Some key issues are: Acceptable sleeping arrangements to allow sufficient rest of acceptable quality. Food should be available throughout the day, as people will be working on different schedules. Mosquito nets must be installed for all the beds, and doors and windows should be screened with mesh. Mosquito repellent and insecticide sprays must be available for all the expatriates. Rodents, bats, flies, and mosquitoes must be strictly controlled in the house. A hand washing station with 0.05% chlorine must be installed at the entrance to the house. There must also be 0.05% chlorine solution available in the bathrooms, and for disinfecting potentially contaminated clothing or other items of the team. The cook must be specifically trained to rinse fresh food and hardware with 0.05% chlorine solution. Consider bringing fresh food from capital, and forbidding the use of local restaurants to avoid risk of diarrhoea. Bathing and shower facilities must be of a decent standard and have a constant, reliable supply of water. As a rule, at least during the initial phases of an outbreak, national and expatriate team should refrain from physical contact, physical greetings (such as shaking hands or kissing), and sexual relations. Helps those team members most in contact with patients to keep used to the “no physical contact” policy, strictly applied in their work environments. Reminds the team (including medical staff and partners) of the dangers to which they are exposed. Reduces the risk of transmission of other diseases with similar symptoms (colds, flu, etc.). Reduces the risk of transmission of VHF within the team. 14.6 Expat Health Medical Precautions Make a file for each expatriate including: information on blood group, vaccine record, type of antimalarials taken, etc. Be proactive in disease prevention: provide drugs, impregnated bed nets, insect repellents, house pharmacy and first aid kit, condoms, water purification, etc. o Ensure everybody takes prophylaxis against malaria. o Clear bats and rodents from team accommodation. Every team member must be briefed about the risks related to his job and the evacuation plan before arrival at the project site. 140 Ensure everybody takes sufficient regular rest. Returning from the mission WHO has stated that no travel or trade restrictions should be imposed for those coming from a country where there has been a recent outbreak of Ebola or other VHF. It is recommended that all expatriates should remain in a country with good health facilities for the 3 weeks after the mission. MSF will extend the contract and provide health insurance for these 3 weeks. Need to verify and arrange visas for expatriates requiring them. Each MSF section should identify hospitals with appropriate isolation facilities. In case of fever occurring within three weeks of returning from the mission, the person must be considered a suspect case until the contrary is proven. Therefore, all precautions to avoid eventual contamination and transmission must be taken. Test for VHF and exclude other causes. 14.7 National Staff Health Medical precautions should be the same as expatriates. Doxycycline is recommended for malaria prophylaxis to avoid possible misuse of Lariam. 14.8 Length of Stay/Working on Outbreak Control Activities It is commonly observed that as members of staff become used to working on the outbreak control activities, their perception of risk and danger, and their attention to safety precautions changes. Initially there is a rapid reduction in risk as they learn the procedures and become accustomed to the various activities and practices. There is then a period where risks are generally lower, but for some people risks actually start to increase again. This may be due to general tiredness, and/or complacency creeping in. This phenomenon illustrates the need for rest, continuing vigilance and the benefits of setting maximum periods that people are permitted to work on outbreak control activities. Risk and Time Risk Risk is relatively high at the start of the intervention before staff are accustomed to protection measures and procedures. Risk declines while staff become accustomed to protection measures and practiced in performing procedures. Risk may start to rise. Staff can become complacent in applying the protective measures, or take shortcuts in their work. Fatigue can also be a factor. Risk is minimised. Staff are practiced in measures and procedures, and the chance of errors and mistakes is low. Time (days) 141 Due to the intensity of this type of intervention, replacements should be made every 6 weeks. The set-up team should be replaced after 3 weeks. For all staff, both national and expatriate, working on outbreak control, 3-4 days of R+R should be taken every 4 weeks. At least one day off should be taken each week. 14.9 Evacuation Procedures The normal systems to protect expatriate health, such as medical and security related evacuation procedures may not be possible. Other countries may not accept evacuated expatriates, and pilots may refuse to fly them despite evidence that it is safe to do so. Therefore, MSF cannot and must not give a 100% guarantee that evacuation will be possible. There are various options for evacuation. Depending on the situation, a person could be evacuated to the capital of the affected country, a neighbouring country, the country of the MSF operational centre, or to the person’s home country. 14.9.1 In Country Evacuation MSF isolation rooms should be set up in the capital and all bases. Planning for in country evacuation must be prepared: Mode of transport o Commercial or charter flight. o MSF vehicle. Medical assistance during evacuation and after. Specific infection control measures o During evacuation. o Disinfection of plane or vehicle. 14.9.2 Regional Evacuation South Africa has health facilities that can safely take in charge VHF patients, and may be an option for regional evacuation. o Each nationality requires specific authorization, and a pre-accord between the two countries is necessary. o Verify the situation for each nationality working on the intervention. The evacuation would be organised and carried out by the medical insurance company (SOS). 14.9.3 Evacuation to Europe Procedures must be negotiated and agreed with the appropriate authorities, insurance companies, etc. Standing agreements with insurance companies for VHF evacuations should be verified for every outbreak. At the beginning of the outbreak, each MSF section should identify appropriate P4isolation level laboratory and health facilities, and transport options (e.g. SOS). Evacuation will not necessary be to the person’s home country. The evacuation would be organised and carried out by the medical insurance company (SOS). 14.9.4 Important Factors Related to Evacuation Asymptomatic Case: 142 An exposed person who is asymptomatic is no risk to others. The window between exposure and development of symptoms (and beginning of period of infectivity) is at least 48 hrs; in fact, it is probably considerably more than 48hrs. Theoretically, there is no risk in using commercial aircraft during the 48hr window period. o However, in practical terms, it could be very difficult to guarantee that an exposed person would be safely received in the host country within 48 hours. o Moreover, if it became widely known that MSF allowed a person exposed to haemorrhagic fever to travel on a commercial aircraft, the negative publicity could be very damaging. Symptomatic Case: If the patient is symptomatic, travel may increase the risk of an adverse outcome. A European hospital can provide health facilities that are not available in the field including extensive laboratory testing; parameter follow-up; blood or plasma for possible transfusion, etc). Despite the presence of VHF clinical experts in the field, intensive care may not be possible and may not save lives; lack of equipment and materials, laboratory facilities and blood products will cause problems. o Consideration must also be given to the increased risk to the health workers and attendants, as there is a temptation to take increased and unacceptable risks to save the life of a colleague. o Family support may be difficult to arrange. 14.9.5 Evacuation Procedures Procedures will depend on the situation. Scenario 1 In case of a working accident: needle or sharp injury; any body fluid on the skin, in the eye, mouth or other mucous membranes. Immediately carry out accidental exposure procedures. See Annex 5.8 Management of Accidental Exposure. This case will be considered as a CONTACT during the incubation period. o The level of possible contamination/infectiousness during this period is nearly zero. Evacuation is necessary. o This may be done in a commercial airline or through SOS Send a blood sample to appropriate lab for viral antibody test. Scenario 2 In case of fever: exclude other causes of fever (take blood sample, perform blood smear, rapid test), and treat accordingly. Blood tests may not be helpful in deciding if the person needs evacuation, as PCR may give false negatives in the first 3 days of symptoms. All patients with fever should be evacuated to the capital to reduce stress to other members of expatriate team. . If there is a significant risk of VHF, evacuation from the country should be considered. The decision to evacuate out of the country should be based on degree of exposure and probability of infection Scenario 3 143 In case of unexplained haemorrhagic symptoms or severe disease with fever: probable case in latest phase. Great care is necessary, as the level of contamination is high. Send a blood sample to appropriate lab and evacuate if possible (taking into account the clinical condition of the patient). At all times, the person should be given appropriate care in a hospital or in a structure where all isolation precautions are in place. In any of the three scenarios, ensure psychological counselling is available and offered to the person. In the case that an expatriate dies of VHF, it may not be possible to arrange the return of the body to their home country. However, if proper cremation facilities exist it would be feasible to return the ashes to the family. 14.10 Job Descriptions Job descriptions are essential for everybody working on an outbreak, and this applies to both expatriate and national staff. It may not be feasible to have specific job descriptions available for all staff on the first day, but task descriptions can be used initially; job descriptions should be introduced as quickly as possible. It must be clear to everybody: What they are required to do. What their responsibilities are. To whom they report. Examples of job descriptions and more generic task descriptions are in Annex 15 Job Profiles and Task Descriptions. 14.11 Stress and Psychosocial Wellbeing Stress is a normal part of life in the field; it is a normal reaction to an abnormal situation. It is the state experienced when faced with a challenge, threat, or change, and where there is a possible imbalance between demands and resources. A VHF outbreak intervention has many demands for which the staff may not be ready or prepared to confront. 14.11.1 Stressors - Demands Some of the most important stressors in a VHF outbreak for both international and national staff are: Fear of becoming infected and dying, coupled with a fear of infecting others. Health staff are at acute risk; health workers may have been infected and some may have died. Confronting and dealing with a very high mortality rate. Curative treatment is very limited; intervention focuses on supportive and palliative care. o Medical interventions are rarely life saving. o Dehumanisation of the patient treatment. Dilemmas resulting from the tension between individual rights (patients not willing to be isolated or treated) and public health priorities. Lack of knowledge and previous expertise of the scientific community in this type of outbreak. This implies: o Risks of being infected and dying are not completely clear. 144 o Limited scientific evidence; difficult decisions have to be made without clear guidelines. o Training to MOH and national staff with incomplete information. Activities, particularly outside the Treatment Unit, often demand “on the spot” improvisation and adaptation to a particular situation or context. The need to use strict personal protection and infection control measures: o Physical strain of using protective equipment – high prevalence of dehydration, physical isolation, heat stress, and exhaustion. o Physical isolation due to the prohibition to touch others, even after working hours. o The constant awareness and vigilance necessary when working in the high-risk area is mentally demanding. This is particularly heightened when introducing new staff to the high-risk zone with the additional responsibility for their safety and their actions, and the extra vigilance necessary. o Lack of clear information on quarantine procedures; in past outbreaks staff ending their mission had contradictory or unclear information related to the risk of infecting others. The community will often stigmatise patients, their families, and both national and expatriate staff. National staff can be ostracized by their families and community. This can also occur to expatriates returning home and at HQ with colleagues avoiding physical contact. Ebola and Marburg symptoms such as bleeding skin, massive diarrhoea, etc. can be shocking for all staff. Exposure to consequences of the epidemic in the community: social network deterioration, patients abandoned by their families, orphaned children, etc. Common symptoms can be misinterpreted; developing a simple fever, diarrhoea, or other ailment is particularly worrying. Common stressors related to any emergency will also be present: long working hours; difficulty maintaining self-care activities for example taking exercise, eating habits, etc.; working within large teams; working with expatriate and national teams with different multicultural and educational backgrounds; constant pressure to keep performing; prolonged separation from personal social networks. 14.11.2 Stress Manifestations In response to these demands, staff might need to manage the following psychological challenges (stress and psychological reactions): Not being able to “cure” patients can cause feelings of helplessness, guilt, and frustration. Only limited care and support can be provided to the patients, families and community, and this can create a feeling of being powerless. Strong feeling of fear of becoming infected and dying, coupled with a fear of infecting others. Psychosomatic manifestations similar to Ebola and Marburg symptoms might appear. Hyper-vigilance and feelings of physical isolation when following infection control protocols, and wearing the PPE. Managing community rejection and lack of understanding can be especially hard for national staff. Communities may lose faith in health institutions, MSF, employers, or government leaders. 145 Cumulative and acute stress reactions present in most emergencies: tiredness, irritability, substance abuse, cognitive problems such as reduced concentration and memory, eating disorders, etc. If the outbreak should take place in a country with projects already running, attention should be given to the other teams in the field. Teams at other sites in the same country will be affected by: The fear that an outbreak causes within the population. Personal fear that the outbreak will affect them. Possible rejection and fear of health facilities – abrupt downsize of activities, staff not willing to come to the hospital, patients not attending, etc. Limited support from the coordination team in the capital, as they will be managing the set up of the emergency intervention. Capital coordination teams will be especially at risk of suffering acute stressors as they have the responsibility of protecting their teams and responding to the outbreak until the emergency team arrives. Subsequent coordination tasks with the emergency teams and governmental and international agencies will also represent an important stressor. For all, other issues that can exacerbate the situation are: Lack of information. Rumours and misconceptions. Mass casualties and deaths among children. Economic collapse or acute shortages of food, water, electricity or other essential services – especially in the case of a zone declared in quarantine 14.11.3 Stress Prevention: Before Mission Put coping mechanisms in place at different levels: institutional, team and individually. The best measure to prevent acute stress is being informed and to have a sense of control. All that can be predicted can be better managed. (See MSF-Holland and MSFBelgium pamphlets on stress in the field). The following information MUST be given as soon as possible to all team members, before departure for expatriates, and before employment for national staff: Medical information on the virus, the modes of transmission and the symptoms. Information about protective measures. Information for families of national staff in order to prevent rejection and lack of understanding. Stressors that will be present. Stress reactions linked to this type of situation. Stress prevention and coping measures to put in place. Information on community reactions in a VHF epidemic. Individual psychological briefings will allow team members to: Assess and understand their strengths and weaknesses. Know what their limitations are. Recognize signs of stress in themselves and others. Prepare individual coping mechanisms to put in place during the emergency. Express and share fears, worries, etc. in a confidential context. 146 14.11.4 Stress Management: During Mission As mentioned above, coping mechanisms can be put in place at different levels: institutional, team and individually. To manage the psychosocial impact of this type of intervention it is recommended that a psychosocial expert is present to support the teams. Not only expatriates and national staff will be in need of psychosocial support, but the staff present at the health facility (or other institutions/agencies) in which the outbreak has been detected and is being managed could also benefit from this support. The aim is to assure the following measures: Adequate rest, and breaks in the working day are extremely important: o Every one must take at least one day off each week (mandatory) and one weekend a month away from the field. o There must be a secure place for teams to rest and relax. o Regular shifts and breaks must be clear and preset; rest breaks should be made systematic and obligatory. o Time at the emergency should not exceed 6 to 8 weeks for any team member; national staff could be transferred to other projects or take one week rest every 6-8 weeks. It is important that the team accommodation is reasonably comfortable, and spacious enough. o Team members should maintain healthy habits (exercise, relaxation, nutrition, etc.) o Hygiene facilities must be available and used (proper showers and washbasins, etc.); in this contagious context, bathing allows a sense of control over the virus contamination. Group debriefing and sharing is important to: o Share coping skills: understand and learn how to manage feelings of fear, helplessness, frustration, bereavement, anxiety, etc. o Make sure there is a clear communication and information flow. o Enable a buddy system, where one colleague watches another in order to warn when they are becoming tired or stressed and therefore at risk. Group sessions have to be programmed in advance and the field coordinator must ensure the logistic structure is available. On an individual level, people should be able to: Recognise and understand their individual signs of stress. Manage their stress, analyse their coping skills and ways of improving them. Express and share emotions, difficulties, satisfactions (in a secure place). Share with the psychosocial support expatriate fears, feelings and worries in a confidential setting. Participate in training and briefing sessions in order to ensure that fear, stress, etc. is not affecting the learning and concentration capacity of the teams (i.e. briefings on isolation methods, infection control measures, transmission, etc.). These recommendations are for all team members, including expatriate and national staff. Cultural differences must be taken into account when carrying out individual and group support. There are some differences when taking care of the person’s social network: For national staff special attention has to be given to the way that their families are responding to the intervention. If they are facing rejection, MSF should assist families to understand and cope with this. 147 In the case of expatriates, if their family is informed of the mission, they should have the means to contact them frequently and directly in order to be able to reassure their families and receive their support. While the family member is involved in the intervention there should be an open line for them to contact their loved ones. In some cases, expatiates do not inform their families for fear of worrying them, in these cases special care has to be taken with the advocacy and press strategy. In order to maintain objectivity and neutrality, the psychosocial support expatriate should rotate on a 20-day basis as maximum. This expatriate must have the support and back up of a mental health advisor at HQ. Input on psychosocial issues, and support for coordination staff is very important in order to assure that the institutional stress factors are managed and that teams have their needs covered. In order to ensure objectivity and independence, the psychosocial support expatriate should be hierarchically independent from the mission coordination team, although functionally he/she would be included in the organigram. 14.11.5 Stress Management: After Mission National Staff Identify local mental health counsellors to ensure culturally appropriate, emotional support. If this is not possible emotional debriefings and follow up (3 months, and where practical one year after) should be done when closing the emergency by the staff psychologist assisted by a cultural mediator. The families of medical staff who die because of the epidemic should be given particular psychological and moral/institutional support. Expatriates Facilitate emotional debriefing upon return home. Facilitate psychotherapy and/or counselling for those who need it to integrate the experience. Offer emotional support to families if required. Offer support and advice to HQ staff on how to manage staff coming back from the intervention (the need to be recognised, to be touched, not judged, and for adequate rest, etc.) Offer follow-up support after 3 months and 1 year. For more information, see I Feel Good on the CD. Back to Table of Contents 148 15 The End of the Epidemic This section deals with the procedures necessary when the epidemic is over. It describes the lifting of service restrictions, closing the isolation facilities, and the withdrawal of MSF. Primary audience: Outbreak Control Coordinators, WHS coordinator. Secondary audience: WHS and Logistics Staff. 15.1 Removing Service Restrictions Services may have been reduced or closed during the outbreak, for example surgery, laboratory testing, and vaccination. Service restrictions that are still in place at the end of the epidemic must be lifted. In order to facilitate the resumption of these services, an information campaign should be carried out to inform the community that the services are available again, and that they are safe. The outbreak may have affected confidence in the health, so a highly visible programme of disinfection and a ceremonial reopening of these services should be considered. 15.2 End of MSF Intervention Analysis of the epidemiological data will assist in determining when to scale down activities in the VHF Treatment Unit. If the outbreak is under control and the number of new cases is consistently reducing, then staffing and activities could be scaled down. If no new cases have been reported for 21 days, the outbreak can be considered to be over, assuming that the contact tracing and case finding activities are reliable and efficient. The Treatment Unit and the associated activities can be closed 21 days after the last reported case. Other activities such as improving infection control, etc. in the hospital and peripheral health structures can be continued until objectives are met. 15.3 Closing Down the Treatment Unit At the end of the epidemic (no new cases for 42 days), the buildings, and facilities should be returned to their original state and use. However, it is possible that the hospital or health authorities will want to retain the set-up as a permanent isolation facility. The decision on how to close the Unit will be made in collaboration with the local medical authorities. If the Unit is to be retained as a permanent facility, the decision on which temporary structures to retain and which to dismantle depends on the quality of the construction and the materials used. An isolation facility that deteriorates and becomes unusable within 6 months has little value. In either case, the compound, buildings, facilities, and equipment must be made safe; all potentially contaminated material must be disinfected, destroyed, and/or made inaccessible (by burying). Where the buildings and facilities are to be returned to their original state and use, they should be repaired and renovated. A fresh coat of paint will help in signalling that the outbreak is over, and should remove any doubts that there is any lingering contamination Temporary structures, for example fencing, latrines and burning pits, must be disinfected and dismantled, and all pits backfilled. 149 Many materials and equipment can be re-used or recycled. However, great care is required to ensure that no materials leave the isolation unit until they are thoroughly disinfected. A “clean zone” can be prepared in the low-risk area to receive and store disinfected materials from the high-risk and low-risk areas. A large volume of equipment and materials will pass through the “clean zone”; therefore, it must be big enough to store everything that will be handled. It should be fenced and thoroughly disinfected prior to starting work. Table 4 - Treatment of Facilities and Equipment When Closing the Treatment Unit Item Bed frames, stretchers and hard furniture Mattress covers Mattresses Plastic materials Clothing – scrub suits etc. Treatment* Disinfection by spraying with 0.5% solution and drying in the sun. Burn, or if in good condition disinfection by immersion in 0.5% solution Burn if suspicion of contamination Disinfection by immersion or spraying with 0.5% solution Disinfection with 0.05% solution, and washing Rubber boots Disinfection by immersion in 0.5% solution Aprons Disinfection by immersion in 0.5% solution Medical equipment Disinfection with 0.5% solution Fencing (plastic sheeting) Disinfection by spraying with 0.5% solution Disinfection by spraying with 0.5% solution and rinsing with clean water Burn disposable and waste items Tents Laboratory equipment Water bladders and plastic pipes Tap-stands Outside Unit – disinfect, clean, and dry normally. Inside Unit – burn if risk of contamination Disinfect by immersion in 0.5% solution and dry in the sun Remarks Destroy if impossible to disinfect If visibly clean, immerse in 0.5% solution, dry in sunlight and reuse Burn items that are damaged or very worn Burn items that are damaged or very worn Burn items that are damaged or very worn Destroy if impossible to disinfect (e.g. stethoscope, sphygmomanometer) Burn if damaged Lab operators will deal with their reusable equipment How to store bladders tech brief PHT 150 Cleaning materials (brushes mops, etc.) Wards and buildings Flush toilets Pit latrines Burn Disinfection of surfaces and walls by spraying with 0.5% solution Disinfection of all surfaces by spraying with 0.5% solution Disinfection of all surfaces by spraying with 0.5% solution Bathrooms Disinfection of all surfaces by spraying with 0.5% solution Grease traps Disinfection by filling with 0.5% chlorine solution Disinfection by spraying Vehicles If temporary latrines – disinfect, dismantle, burn superstructure & backfill pit Bathrooms – disinfect, dismantle, burn superstructure & backfill soakaways If temporary - backfill Must be rinsed after disinfection Sharps pit Encapsulate contents with If permanent concrete slurry construction – can continue to be used after partial encapsulation Organics pit Encapsulate with concrete If permanent slurry construction – can continue to be used after partial encapsulation Burning pit Encapsulate with concrete If permanent slurry construction – can continue to be used after partial encapsulation *Any metallic items and items that will subsequently be in contact with the skin e.g. boots, mattress covers, should be rinsed with clean water once disinfected. Back to Table of Contents 151 16 Other MSF Projects in Areas Experiencing a VHF Outbreak This section describes the measures and precautions that should be taken by MSF projects that are running in a country/region affected by an outbreak. Primary audience: MSF Project Coordinators, Outbreak Control Coordinators Secondary audience: MSF Project Staff. It is important to distinguish between medical and non-medical projects, and projects that are being implemented within the outbreak area and those outside but within the country or region. Depending on the nature of the projects, the measures and precautions necessary in the outbreak area can be quite strict. For projects outside the outbreak area, fewer restrictions and precautions are required. 16.1 Projects within the Outbreak Area 16.1.1 Medical Projects The precautions and restrictions necessary to implement will be similar to those implemented for health structures as described in Chapter 9 Infection Control outside the VHF Treatment Facility. Heightened vigilance, improved infection control measures, and basic training are necessary. The basic training for all staff should cover the disease, the risks, and protection measures. Provide training on specific issues for staff working in direct contact with patients; this would include identification of VHF patients using case definitions, Standard Precautions and Additional (transmission-based) Precautions, use of PPE, and infection control. A contingency response plan must be prepared. This would include identifying a room or area that could be used as an isolation facility and planning the set-up, identifying and training staff who would care for a suspect VHF patient, determining whether transfer of patients to an existing VHF Treatment Unit is feasible and planning how that would be done. An Assessment Kit (as described in Annex 17.1 Assessment Kit) should be readily available, and staff trained in the use of the kit. Pre-positioning of the Basic Health Centre kit as described in Annex 17.2 Health Centre Kit should be considered; this kit allows health workers temporarily to take in charge a suspect VHF case. 16.1.2 Non-Medical Projects The risk to staff working on projects that do not have a medical component will be minimal, however heightened vigilance is important, and contingency planning should be done. Provide a basic training about the disease, the risks, and protection measures for all staff. 16.2 Projects outside the Outbreak Area 16.2.1 Medical Projects There is always a risk that the outbreak can spread if an infected person were to travel to a new area. Therefore, basic training, and training on diagnosing VHF cases should be done at the least. 152 16.2.2 Non-medical Projects Provide a basic training about the disease, the risks, and protection measures for all staff. Back to Table of Contents 153 17 Ethical and Human Rights Issues Relevant to VHF This section deals with human rights issues that are relevant to VHF outbreaks and control. Primary audience: Outbreak Control Coordinators. Secondary audience: All persons involved in outbreak control activities. 17.1 Experimental Drugs and Procedures There is still quite limited knowledge about Ebola and Marburg haemorrhagic fevers but many research and academic institutions are currently conducting research into these diseases. Due to the limited treatment options and the high mortality rates, effective drugs and treatment methods are urgently required. Drugs and vaccines have been developed which may have a beneficial effect on patients suffering from the disease and patients incubating the disease. However, trials of these drugs have been carried out mainly on non-human primates; clinical trials on human subjects have been restricted to testing for adverse reactions to the drugs. It is highly unlikely that trials involving challenging human subjects with the virus would ever be contemplated; similarly, trials during an outbreak that would involve a control group of untreated patients would not be ethical. Opportunities for clinical research on humans actually suffering from VHFs are rare and depend on the occurrence of outbreaks. If the use of the experimental drugs or procedures is contemplated, then the following principles must be ensured: Essentiality: the research must be necessary for the advancement of knowledge. Informed consent and voluntary participation. Non-exploitation: Participants must be kept fully informed of all risks, and compensation may be considered. Precaution and risk minimization. Professional competence. Accountability and transparency. Proposals for research utilizing experimental treatments will be subject to approval by the MOH, and the ethical board of the institution proposing the research must approve the proposal. Any proposal for MSF staff to be involved in performing experimental treatments must be carefully analysed and must pass an ethical review committee within MSF. Contact headquarters for advice. 17.2 Patient Consent and Confidentiality Ensuring patient consent and confidentiality is standard practice and this practice should not be altered in an outbreak. However, even though maintaining confidentiality is essential, patient information, particularly epidemiological information, has to be shared with other organisations in order to facilitate the activities aimed to contain the epidemic (contact tracing, case-cluster investigation, etc.). All organisations involved must agree to maintain confidentiality; all information must be handled in a manner that protects the privacy of patients and their families. The clinical information can be shared with health authorities. The epidemiological information has to be shared daily with the epidemiological surveillance team. 154 The psychosocial information can be shared with partner organisations working in social-economical recovery sector. 17.3 The Role of the Military in Outbreak Control Interventions During an outbreak of Ebola or Marburg, the government is under intense pressure to manage and control the situation. Mobilising the military forces of the country is one way that they can try to take the situation in hand. This is a very visible response and can be implemented easily and quickly. The military often have significant resources, and in past outbreaks, military forces have been utilised for grave digging, grave security, and the burial of abandoned bodies. There is a possibility that the authorities will demand that the military forces play a larger role. However, soldiers may not be the best people to carry out the more sensitive tasks, for example negotiation and discussion with fearful and distrusting families. There is also a risk that soldiers may resort to force to ensure that all patients are isolated. Obviously, coercive isolation and hospitalisation at gunpoint will do more harm than good. This must not be allowed to occur. If the military are to be involved in the outbreak control activities, their role should be limited to unarmed logistical and engineering support under civilian leadership. There must be clear agreements on what they will do, how they will operate, and to whom they must report. They must receive appropriate training, and they must understand the risks and the measures necessary to deal with them. 17.4 Mass Quarantine of Populations Isolation is the separation and restriction of movement of ill persons with a contagious disease. Quarantine is the separation and restriction of movement of well persons presumed to have been exposed to contagion. It is sometimes proposed to implement mass quarantine of populations in areas affected by outbreaks of viral haemorrhagic fevers. This is usually a “knee-jerk” reaction of the authorities that is rooted in fear and a lack of understanding of the diseases. However, individual isolation and treatment of persons suffering from VHFs or suspected to be suffering from these diseases is a different matter, and this form of quarantining is a valid approach. Where mass quarantine is proposed, three major questions must be considered: 1. Do public health and medical concerns warrant the imposition of mass quarantine? 2. Is the implementation and maintenance of mass quarantine feasible? 3. Do the potential benefits of mass quarantine outweigh the adverse consequences? In principle, mass quarantining of entire villages and regions is not a recommended approach to dealing with outbreaks of Ebola and Marburg for the following reasons: 1. The beneficial effect is limited, and it is an over-reaction to the risks. 2. It would require significant resources to implement, which could be better used for other activities. 3. The negative repercussions of such an approach outweigh any possible benefits. a. It would cause even more panic and add to the already significant levels of fear in the communities. 155 b. There is also the risk of increasing stigmatisation and discrimination within and from outside the affected communities. c. It can create bad feeling, distrust, etc. and future cases are more likely to be concealed. d. It would cause unnecessary disruption to people’s lives and livelihoods. The implementation of mass quarantine raises several issues. A key issue is effectiveness. It is most useful for easily transmitted diseases, and cases are infectious and asymptomatic during the incubation period: this is not the case with Ebola and Marburg. These diseases require close contact in order to be transmitted and are unlikely to be spread through the general population; furthermore, transmission is possible only when cases are symptomatic. Mass quarantining would have very limited effectiveness, and forced, mass quarantine of entire regions and/or villages is disproportionate to the risk, and shifts from being a public health issue to become a human rights issue. Another important issue is ethical: it is a widely held view that mass quarantine is unacceptable in terms of personal liberty and rights; however, it can be argued that in certain circumstances the public good should take precedence over the rights of the individual. This argument would not be valid for an outbreak of Ebola or Marburg, as mass quarantine would provide little or no benefit. If the situation arises, where local authorities wish to implement mass quarantine, then every effort should be made to discourage this action, and to encourage the direction of resources and actions towards community sensitisation and education, and the installation and promotion of appropriate isolation and treatment facilities. Back to Table of Contents 156 18 Dealing with the Media This section briefly describes the challenges and opportunities that arise with media interest and coverage of outbreaks. Primary audience: Press officer. Secondary audience: Coordinators. Both Ebola and Marburg suffer from a high level of mystification and sensationalism. They are popularly considered as the most deadly and dangerous “mystery killer diseases” that exist. However, knowledge about these diseases is continuously improving, and the dissemination of this knowledge is contributing towards reducing the most sensational news reports, and helping to demystify the diseases themselves. When dealing with the media it is important to provide information that illustrates the human element of the outbreak. This can help to humanise the issues, and perhaps reduce the sensationalism. Take care to avoid statements that could increase panic in the population. There is frequently a great deal of interest from both local and international media during an outbreak. This interest can be harnessed to provide an outlet for messages and information. Messages must be simple, clear, and specific to the context. There should be a focus on positive concrete measures; messages should be take account of the following concepts: 1. Susceptibility – how could the outbreak affect you and your family? 2. Efficacy – steps to take to protect yourself and your family. 3. Benefit – the benefits from carrying out the suggested actions. It is very useful to have one designated spokesperson to deal with the media to ensure that the information provided is consistent and accurate. It is very important to provide this information to the media as quickly as possible. Otherwise, less accurate and possibly contradictory information and recommendations may fill the “information vacuum”. The media have a job to do, and in this context, the objective should be to make their job as easy as possible by providing them with the right information and the right messages. Information and recommendations provided to the media must be accurate and complement the messages that are disseminated via the health promotion and social mobilisation activities. Any contradictions or confusion in this regard could have a serious effect on the acceptance of the health messages and activities. It is important to monitor the local, national, and international media reports to ensure that they provide accurate information, and that they are “helpful” with regard to the outbreak control activities. Back to Table of Contents 157 Annex 1 Filovirus Information Annex 1.1 Understanding Filoviruses The majority of the information on filoviruses is included in the main part of the text; this annex gives some additional specific information relevant to medical staff treating the disease. Pathophysiology The virus can replicate in a large variety of human cells. Macrophages and dendritic cells are generally the first cell types to be infected, and their infection affects their functioning, inhibiting the presentation of antigens to lymphocytes, and interfering with the secretion of immune regulating factors. This causes an immune suppression. As the disease progresses parenchymal cells, like hepatocytes and adrenal cortical cells, are infected, and finally epithelial cells and fibroblasts. The infection can affect almost every organ in the body, and cause widespread cell death. Bleeding, when it occurs, is caused by disseminated intravascular coagulation (DIC), probably due to the activation of macrophages and the release of pro-inflammatory cytokines. There may be apoptosis of lymphocytes late in the disease course, causing further immuno-suppression. The case fatality rates for VHF infections have generally been reported as being between 50-90% in an African setting, depending on the strain of virus. Some types, like some strains of Ebola Zaire, have been shown to cause severer infections than others do. The chances of survival of individual patients are linked to the effectiveness of their immune response. Mild cases occur due to an effective immune response with little immunosuppression. Recovery occurs after 10-14 days of illness, and is associated with the appearance of effective anti-bodies. Although this variability of survival and of immune response between patients has been used to argue that survival may depend little on medical care, there is evidence that good supportive medical care improves outcome. The first outbreak of Marburg in Europe had a much lower case fatality rate than other epidemics of the same disease, probably due to the care given. It needs to be noted that in the final stages of the severe illness, the presence of fever may not be a reliable sign, and many patients with severe disease may be apyrexial. This can therefore not be used alone to guide diagnosis or discharge. Some General Points on Treatment At present, there is only supportive treatment for VHF infections. No specific treatments have been identified; however, research has been done on treatments that may improve the outcome of the DIC or generalised inflammation (see section on possible future treatments, below). Heparin has been used widely for the treatment of DIC in hospitals in developed countries, but its use generally requires monitoring. Its use is not recommended in a field setting at present. The supportive and symptomatic care for these infections is outlined in annexes 4 and 5. The general principles are the same as the principles of treatment for other conditions. However, some medicines should not be used on these patients: Aspirin and NSAIDs: These are not recommended due to affects on platelet function and clotting, and due to the risk of peptic ulcers. 158 Steroids: These are not recommended due to possible suppression of the immune response. Treatments should be chosen which pose the least risk to personnel. This normally involves giving all treatments by mouth if possible. If injected treatments are to be given, medicines with long half-lives should be chosen so that the number of injections given can be as low as possible. For this reason antibiotics like ceftriaxone, which only need to be given once a day, are preferred. Possible Future Treatments There are a number of current avenues for research for VHFs, including vaccines that are currently undergoing testing. Two treatments that may improve the survival in people with VHF infections are activated protein C and rNAPc2. rNAPc2 is a recombinant tissue factor inhibitor that reduced clotting and may improve survival in patients with DIC. It has shown promising results in small tests on monkeys, and is currently being tested in humans for patients with ischaemic heart disease and for operative thrombus prophylaxis (both at a much lower dose than may be needed for DIC). The severity of VHF may merit its use as an experimental treatment, although consent would be required. Asking for consent to use experimental treatments may have a negative effect on the community’s perception of our service. It is recommended that at the beginning of any future epidemic, up-to-date information on these treatments be examined. Annex 1.2 Diagnosing Filoviruses General Points The Case definitions are extremely useful in the detection of VHF patients. The suspect case definition is normally very sensitive, but not very specific (it should detect almost all cases, but will include many patients with other conditions). The probable definition is generally less sensitive, but much more specific (it will include fewer patients with other conditions). The suspect case definition is used for screening of cases, and in the absence of a laboratory, the probable case definition may be used to help decide who needs isolation and treatment as a VHF patient. However, these case definitions can never fully replace the decision-making ability of an experienced clinician. For example, many patients who conform to the case definition can easily be discounted, as it is clear that they have other conditions. An example of this is people who have chronic symptoms. All these case definitions need to be applied sensibly, not rigidly. In the absence of a laboratory, the case definitions and clinical judgement of the clinicians involved must be used to diagnose these conditions. However, in recent years a number of useful tests have become available to improve the diagnosis of these conditions. Currently Available Laboratory Tests There are a number of useful laboratory tests available. However, this is a rapidly developing field and more information on the accuracy and use of these tests is available with every epidemic, and the tests may vary between the different strains of VHF. It is 159 strongly recommended that the use of these tests be discussed with the laboratories involved at the beginning of any epidemic. Currently available tests are: rt-PCR (reverse transcription PCR). This test can detect strands of viral RNA in the sample given. Generally, probes are used to two or three segments of viral RNA. A wide selection of sample types can be tested (blood, swabs, vomit etc), but generally blood samples or oral swabs are used. They are the most useful tests for the clinical management of VHF cases in the field, and their use is described in more detail below. IgM Serology (ELISA). An IgM ELISA test has been developed, and this requires less technology than the PCR. IgM antibodies can appear early in the disease, but this cannot be relied on in the first few days. Due to immuno-suppression, the immune response to the virus is variable. There have been concerns about the sensitivity of some of these tests, and they may not be helpful. The current situation needs to be discussed with the laboratory at the start of the epidemic. IgG Serology (ELISA). An IgG ELISA test is available for VHFs. However, the appearance of IgG antibodies generally occurs late in the disease course (after 10-14 days of symptoms) and is normally associated with clinical improvement. Therefore, these tests are not very helpful in the management and isolation of clinical cases. They are more helpful for the posthumous diagnosis of cases to guide contact-tracing activities. Antigen detection, virus culture and skin biopsy tests. These tests are also available but are likely to be of less use in a field setting. They can be discussed with the laboratory involved. The Use of PCR Tests Generally, the PCR tests are likely to be the most useful in the field setting, and are the only ones described here. The commonly used tests are: Oral Swab: These are collected by rubbing a swab along the area where the teeth meet the gums, and this should be done along the line of the front teeth of both jaws. It is best done firmly to enable cells to be collected. Generally, the concordance between this test and the blood test are good, especially in severe disease and in dead patients, where the viral load is high. It is currently recommended that only the blood test be used to rule out the disease, as it is considered more sensitive. Blood samples: Unclotted blood can be tested for the virus, and this is generally considered the most sensitive test. Single fragments of viral DNA may be detected, and the virus normally infects white cells (mainly monocytes and macrophages) early in the disease course. However, even this test may not be accurate in the first few days of symptoms. Current recommendations on the use of these tests are: The test is not used in the incubation period or in asymptomatic patients. The test is very unlikely to detect the virus in these circumstances, and is not helpful. Any positive result (blood or swab) confirms the disease (the test is considered very specific). Only the blood test is used to rule out the disease, the swab is less sensitive. 160 In the first 3 days of symptoms, the viral load is low and the test may not be sensitive. If the disease is suspected and the result is negative, the test needs to be repeated on or after the 4th day. Negative blood test results after the 3rd day of symptoms are generally accurate. However, if the clinical suspicion is extremely high (e.g. typical symptoms and strong contact history), it may be worth repeating the test on the next day. Two negative blood tests after the 3rd day of symptoms mean that those symptoms are not due to a VHF infection. The tests can also be useful on recovering patients. Following a VHF infection, most patients are very weak and they may be immuno-suppressed, causing them to suffer prolonged problems that are not directly due to VHF. They can be assumed no longer infectious if there are two negative blood PCR results (on good samples) at least 48 hours apart. In this situation, it can be considered safe to discharge the patient to a normal hospital ward. Back to Table of Contents 161 Annex 2 Sample Collection and Transportation Annex 2.1 Collection of Confirmatory Samples When a VHF outbreak is suspected, confirmation must be done through laboratory testing. This testing can only be done at a small number of laboratories that are equipped with Biosafety Level-4 (BSL-4) facilities. (For contact details of BSL-4 laboratories, see Annex 16.1 Main Filovirus Testing Centres). In some circumstances a field laboratory will be available, different sampling procedures may be used depending on the requirements of the laboratory, however the fundamental principles will be the same as described here. Collection of Samples The sampling methods and procedures will depend on the testing processes to be carried out. Before taking samples verify with headquarters and/or WHO and/or the laboratory exactly what is required. General Principles Before taking any samples, identify and inform the laboratory to which they will be sent. Verify the sampling procedures required. Notify the laboratory that suspected VHF samples are being sent to them before dispatch. It is essential that protocols be followed for sampling to ensure that the samples will be useful and valid. All samples must be properly labelled and accompanied with a clinical description of the suspect case(s). All samples must be safely packaged using a triple-packaging system, and stored and transported according to protocols. The use of PPE, disinfection and waste disposal measures are essential while taking samples. The Sampling and Assessment module (Module 7) of the standard MSF Ebola Haemorrhagic Fever Kit contains all materials and equipment necessary for safely carrying out an assessment: examining patients; collecting samples; and packaging and transporting the samples according to IATA regulations. The Sampling module (Module 5) contains only the sampling and transportation material. An explanation of which material is used for the different sampling methods is given in each module list and description; see Annex 17 Contents of Ebola Kit . Table 5- Sampling Methods, Storage & Shipping Type of sample From whom Whole blood in dry tube (vacutainer) Living suspect cases. Suspect cases shortly after death. Whole blood dried on filter paper. Suspect cases. Skin-snip Dead suspect cases. Ideally take skin snip from the eyelid. If not possible, take in nape of the neck. Liver biopsy (punction) Dead suspect cases. 162 Storage Shipping Sample will have most value if cold chain is respected. Preferably frozen: (between –70and -80°C) If freezing not possible, keep cool. Avoid temperature variations. (See Remark 2) Ideally dry ice or ice packs at -70 or -80°C. IATA-regulated: "Infectious Substances". (See footnote 8) Possible testing if well handled Viral antigen, IgG and IgM antibody, viral RNA, virus isolation. Remark 1 If sample is taken and handled well, this will provide the most complete testing results. Remark 2 After collection: do NOT dry by heat or in the sun. Store sample in cold dry conditions. Can be stored and sent at room temperature for short time (1 week), but this can diminish the testing value of the sample. Fix in 10 % formalin. Can be stored at room temperature. Is not infectious once fixed in formalin. Do NOT freeze. Do NOT freeze. Can be sent by normal mail, but pack in triple packaging. IgG and IgM. Viral antigen. (Immunohistochemi stry). Only useful when virus titres are extremely high (acutely ill persons, or persons who have died from Ebola). Different sensitivity for different viruses and sub-types (EBO-Z =~ 100%; EBO-S =~70%; Marburg =~ 50%). Cannot be used for all VHFs. Fix in 10 % formalin. Can be stored at room temperature. Do NOT freeze. Is not infectious once fixed in formalin. Do NOT freeze. Can be sent by normal mail, but pack in triple packaging. Viral antigen. Should ONLY be done by physicians experienced in biopsy sampling. More viruses can be tested than with skin snip. Annex 2.2 Transportation & IATA Regulations The transport of certain samples (see sampling table above), are subject to strict ICAO (International Civil Aviation Organisation) / IATA (International Air Transport Association), UPU (Universal Postal Union) regulations concerning packaging, labelling and transport. Further to the regular ICAO / IATA and UPU regulations on Infectious Substances and Diagnostic Specimens, there are also State Variations and Operator Variations. Due to frequently changing regulations, and the variations depending on operator and country, an exact description of the procedures is almost impossible. Verify with the medical department in headquarters and if possible the WHO representative how to proceed for each specific case. See WHO Transport of Infectious Substances 2007.pdf on the CD. 8 Shipping should normally be done according to “Infectious Substances” regulations, however an agreement exists between IATA and WHO that allows the shipping of blood samples under the “Diagnostic Specimens” regulations as long as one is not sure that they contain the Ebola or Marburg virus. 163 General Requirements (For information only - check before shipping) ! For both Infectious Substances and Diagnostic Specimens a basic triple packaging system must be used. Basic Triple Packaging System Samples have to be packed in three containers. Inner watertight container, containing the sample. A second watertight box, containing enough absorptive material surrounding the first box, in order to absorb all the fluids of the sample in case of leakage of first box. Outer shipping package that protects the secondary box from physical damage and water. Specimen data forms, letters, and other information regarding the specimen, and identification of the shipper and consignee identification should be attached to the outside of the second container. Triple Packaging Diagnostic Specimens Blood samples on filter paper. Skin snip, Liver biopsy. Blood Sample on Filter Paper Skin Snip Biopsy Equipment Packaging Basic triple packing must meet the packaging instruction (PI) 650. Primary receptacles may contain up to 500 ml each, the total volume of the outer package may NOT exceed 4L. Note: The packing materials in “module SAMPLING & Assessment” of the Ebola Kit, meet the required specifications. Labelling of Outer Packaging 164 A label with the following information is required: Name, address, and telephone number of consignee. Name, address, and telephone number of shipper. The statement: “Diagnostic Specimen, Not Restricted, Packed in Compliance with Packing Instruction 650” The infectious substance label (biohazard) is NOT required. UN specification marking is NOT required. Required Shipping Documents Packing list & pro forma invoice, including following info: o Number of boxes; details of contents; consignee address; sender’s address; weight (optional); value (for samples with no value, mark “no commercial value”). The shipper’s declaration of dangerous goods is NOT required. Airway bill (if shipped by air). Copy of specimen data forms, letters, and other identification data. o One copy must be attached to the outside of the second container. o One copy to be sent (by airmail) to receiving laboratory. o One copy stays with sender. Infectious Substances Liquid Blood in vacutainer9 ! International air carriers strictly prohibit hand carriage, and the use of diplomatic pouches for transporting infectious substances. Packaging The basic triple packaging must meet with the UN class 6.2 specifications and packaging instruction (PI) 602. The maximum net quantity of infectious substances in outer shipping package is 50 ml or 50g for passenger aircraft and 4L / 4Kg for cargo plane or other carriers. Labelling A label with following information is required: Name, address, and telephone number of consignee. Name, address, and telephone number of shipper. UN number and proper shipping name. Packing list & pro forma invoice and airway bill (as described above). Temperature storage requirements (optional). The infectious substance (biohazard) label must be put on the outer packaging. If packaging exceeds 50ml or 50g, two package orientation labels (arrows) indicating the UP side must be placed. Required shipping documents 9 Shipping should normally be done under “Infectious substances” regulations, however, an agreement between IATA and WHO exists which allows to send blood samples under “diagnostic specimens” as long as one is not sure that it contains the Ebola virus. 165 The Shipper’s Declaration for Dangerous Goods. Packing list, pro-forma invoice, and air waybill (as described above). Copy of specimen data forms, letters, and other identification data. o One copy must be attached to the outside of the second container. o One copy to be sent (by airmail) to the receiving laboratory. o One copy stays with sender. Requirements for Air Mail Both Infectious Substances and Diagnostic Specimens may be shipped by registered airmail. Basic triple packaging system must conform to Infectious Substances or Diagnostic Specimens requirements. Green Customs Declaration Label for Postal Mail (international mail) Address label must display the word “LETTRE” Required for Diagnostic Specimens: Violet UPU “Perishable Biological Substances” label. Required for Infectious Substances: Biohazard label and Shipper’s Declaration of Dangerous goods. 166 Annex 2.3 Standard Form for Submitting Laboratory Samples VHF Laboratory Test Request Form Physician requesting test: Date: Sex: / M / Patient name: F Barrio, village: Age: Identifier number: Clinical Information Admitted in isolation unit? Yes Onset of symptoms: No / Date of admission: / / / Previous contact: Yes No Fever Yes No Headache Yes No Diarrhoea Yes No Bloody diarrhoea Yes No Vomiting Yes No Bloody vomit Yes No Fatigue or weakness Yes No Cough Yes No Sore throat Yes No Muscle or joint pain Yes No Chest pain Yes No Rash Yes No Haemorrhagic signs Yes No Type of signs Other Symptoms: Sample Information Sample type: Oral Swab Nasal Swab Date and time sample taken: Type of test: ___ Blood Other_____________ / / am/pm / / am/pm __ Laboratory Information Date and time sample received: Result: Positive Remarks: ___ Negative Date of results: / / __ 167 Annex 3 Anthropological and Social Issues Annex 3.1 Rapid Assessment Checklist The following checklists give examples of the types of questions that it is necessary to answer in order to prepare information and behaviour change messages. The information collected will help determine the best methods of delivery, and to adapt the intervention activities to be appropriate to the anthropological, and socio-cultural context. Checklist for Health Related Questions (to be adapted as required) Questions to Answer What terms do people use for illness? What is the term used for the current illness? What are its signs and symptoms? Is it perceived as being abnormal? How do people believe illness is caused in general? How do people think that the current illness is caused? How may it be prevented? Where and how can it be treated? What is its prognosis? Do people believe in contagion as a source of illness? Are there local hygiene beliefs? What are the local hygiene beliefs? What are the local beliefs with regard to touching both the well and the sick? Who traditionally cares for ill family members? Who traditionally tends to corpses, and performs the funerals? What are the terms for “clean”, “unclean”, “safe”, “unsafe” Are excreta or body fluids viewed as “unclean” or “unsafe”? What are the traditional responses to illness? What are the traditional taboos associated with illness? What are traditional responses to individual illness? What are traditional responses to community wide illness? Are there special occurrences that supersede normal traditions? Are there instances when isolation or limiting contact with the sick is practiced? How is this isolation or limited contact done? What is involved in a proper traditional burial? What are the implications of being buried without traditional rites? Are there circumstances that allow for suspension of traditional burial practices? What are the likely barriers to behaviour changes? Remarks There may be many, depending on the perceived cause of illnesses. Sorcery/witchcraft, environmental factors. Does this change as the outbreak progresses? Both modern and traditional treatments. With and without treatment(s). When, how, who. Male/female, age, position in family. No relatives? Male/female, age, position in family. No relatives? Adults, children, infants, male/female. Location, contact with the sick, duration. Temporary and long-term changes? N.B. – use of the term illness, i.e. absence of well being, as distinct from disease. In some cases, ill health may be attributed to natural and/or supernatural phenomena (e.g. exposure to excessive heat or intercession of spirits) and possibly viewed as distinct from disease, if disease is even used for explanatory purposes. 168 Checklist for Operational and Cultural Related Questions Questions to Answer Do people know what MSF, WHO, etc. are doing? Have people seen or heard any of the 1st phase messages? What did they think of the messages? What are the rumours that they have heard? Has the community had previous experience with outside help with health matters? How has previous outside help been perceived? Remarks Were they appropriate, did they believe what was said? The disease, MSF, etc. Which ethnic groups are living in the area? Which religious groups are living in the area? What are the relationships between the different groupings? Who are the community leaders? Who are the traditional leaders? What are the responsibilities and roles of the leaders? Back to Table of Contents 169 Annex 3.2 Information Leaflets & Posters from Previous Outbreaks – English Versions 170 Gulu Information Leaflet 171 172 Gulu 2000 Information Poster 173 Examples of Posters Used to Provide Information to Family Members of Ebola Patients. Kikwit, 1995. Avoid contact with patient's blood, urine and vomit. Do not touch or wash the bodies of deceased patients. Burn needles and syringes immediately after use. Use gloves to handle the patient's clothing. Boil soiled clothing before washing it. Back to Table of Contents 174 Annex 4 Site Assessments and Planning Annex 4.1 Site Assessment Form for Health Centres Date: Name of Health Centre: Population served #: Name - Medical officer: Observer: District: # Beds/Patients: Name - watsan/tech: VHF cases reported #: Referred to: Medical Type of health structure? Services offered? # Beds & ratio beds/m 2 Attendance rate? Laboratory? Invasive procedures used? Minor surgery? Infection Control VHF Triage? Standard precautions? Disinfection and sterilisation procedures? General hygiene: cleaning, laundry, etc. Availability of equipment and materials? Management of flow of patients, visitors, etc. Excreta Disposal Type of latrine? Walking distance? State of repair? # Latrines for patients? # Separate latrines for VHF patients? # Latrines for staff? Separation VHF latrines from other latrines? Possibility to increase # latrines? Access for elderly, disabled, children? Pit cover available/used? Flies seen? Functioning handwashing facility? Anal cleansing material? (Present?) / Hours of operation: Y N N/A Y N N/A Y N N/A Y Y N N N/A N/A Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A Y Y N N N/A N/A Y N N/A Water Supplies Type of supply? Pumping method? 175 Protection measures? Walking distance? Quality of water? State of system? Water supply in HC? Chlorination? Water in dry season? Used by community? Distance from latrine? Y Y Y Y Y N N N N N N/A N/A N/A N/A N/A Y Y Y N N N N/A N/A N/A Y N N/A Y Y N N N/A N/A Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A Y Y Y N N N N/A N/A N/A Y N N/A Y N N/A Y N N/A Y N N/A Y N N/A Waste Disposal Type of facilities? Walking distance? Protective measures? State of repair? Segregation waste in HC? Collection of waste in HC? Disposed regularly? Safe disposal of sharps? Safe disposal of organic waste? Safe disposal of solid waste? Awareness VHF waste? Health & Hygiene Promotion # Health promoters? Facilities/messages being promoted? Visible signs of promo? Campaign messages put into practice? Appropriateness? Community participation? Awareness of VHF? General Location? Management of health structure? Facility to host patients? Separation patients and VHF patients? VHF training received? State of building? State of inventory? Storage facility? Source of patients’ food? Bathing facility present? 176 Annex 4.2 Example of Plan of Isolation Facility LEGEND : LOW RISK ZONE HIGH RISK ZONE Store room Latrine + bathroom Chlorine hand washing Probable/confirmed cases’ ward or rooms Laundry lines HIGH RISK ZONE Probable/confirmed cases’ ward or rooms Laundry area Morgue Chlorine preparation Expansion probable/confirmed cases’ ward or rooms Waste window Guard Chlorine footbath +spray waste Corpses STAFF Outer fence Changing room 2 Spray or dip Sharps pit LOW RISK ZONE Expansion suspected cases’ ward or rooms Organic waste pit Inner fence Suspected cases’ ward or rooms Doctor’s room Suspected cases’ ward or rooms Burner and pit HIGH RISK ZONE Guard +spray Changing room 1 OUTSIDE STAFF Screening room Slope down PATIENTS 177 Annex 4.3 Example of Plan of Changing Rooms Outside to Low-Risk Low-Risk to High-Risk LOW RISK AREA gloved hand washing HIGH RISK AREA Spray or dip chlorine foot bath chlorine foot bath how to dress up how to undress how to dress up waste bin for gloves, etc washable items mirror how to dress down gloves washable items: apron goggles waste bin: gloves, etc waste bin gloved hand washing BENCH or LINE BENCH or LINE street clothes changing cubicle male street shoes head cover goggles mask crossing line apron gloves gown crossing line waste bin changing cubicle male bare hand washing boots changing cubicle female changing cubicle female dirty scrub suits INNER FENCE gloved hand washing bare hand washing street shoes spraying new gloves new scrub suits Guard + spray STAFF EXIT STAFF ENTRANCE boots spraying OUTSIDE TREATMENT UNIT Guard + spray STAFF EXIT STAFF ENTRANCE LOW RISK AREA 178 Annex 4.4 Examples of Layouts of Previous Isolation Facilities Chlorine Preparation High-Risk zone Latrines & bathing Suspect tent Latrines & bathing Undressing area. Probable room Suspect room Suspect room Suspect room Suspect room Probable room Veranda Veranda Undressing area. 2nd Changing Area Laundry Waste Pit Nurse/Dr’ tent Nurses’ tent. Dressing Chlorine Preparation Low-Risk zone ` Initial Setup Yambio, Sudan. In the beginning, patients were already accommodated in the rooms. A basic setup was done to allow safe entry and exit from the rooms. Latrines & bathing 1st Changing area Probable tent Waste Pit Store tent The initial suspect and probable rooms shown were the only permanent buildings; all other facilities were installed using tents, or plastic sheeting structures. Staff entrance Morgue Staff latrines ` Final Setup Yambio, Sudan. The facility was subsequently enlarged and improved. Low and High-risk areas were arranged; separated latrines and bathing areas were installed, along with a morgue, and changing areas. No lab was present so four separate suspect patient areas were installed. 179 Initial Setup Uige, Angola. The hospital authorities made a large part of the hospital compound available to be used as the VHF Treatment Unit. Almost all facilities were installed in permanent buildings. Improvements to Setup Uige, Angola. Arrows indicate direction of staff flow. The areas for High-Risk zone dressing & undressing were separated. A third entrance was arranged for the movement of corpses. Laundry & chlorine area Staff Entrance Changing Room 1 Low Risk Zone Latrines & Bathing Existing Building Undressing area Unused Building Changing Room 2 Store Probable Area Chlorine Preparation Area Suspect Area Confirmed Area High Risk Zone Morgue Waste Zone Latrines & Bathing Patient Entrance 180 Gulu, Uganda. The facility was installed in and around an existing hospital ward. The separation of high and low-risk zones was not structured as in later installations. The 2 wards were considered high-risk areas. Staff Entrance Changing Room Training Tent Footbath Aprons WC & Bathing Cl prep Confirmed & Probable Cases Ward Suspect Cases Ward Dr ‘s Room Store WC & Bathing Triage Laundry Patient & Vehicle Entrance 181 Annex 4.5 Summary of Facilities in Different Risk Zones Summary of Facilities in the High-risk Area Risk Zone Areas & Activities Facility Suspect patient accommodation High-risk Zone Suspect Patients Suspect patient latrines Less than 25m from wards. 1 male, 1 female 1 per 20 patients Suspect patient bathing areas Less than 25m from wards. 1 male, 1 female Suspect patient laundry area 1 slab & drying lines Water points 1 or 2 taps Suspect patient compound Chlorine preparation Probable patient accommodation Probable / Confirmed Patients Location - Space - Quantity Common ward with bed separators or single rooms. Provide separated spaces for cohorting of patients. Direct access from suspect patient accommodation. Open air with shaded areas. Close to water point. Shaded area for preparation and storage of chlorine solutions. Common ward with bed separators or single rooms. Provide separated spaces for cohorting of patients. Size Recommended Material & Alternative Material Allow 2m separations between beds for easy access. ≈10m2/bed Existing buildings. Tent or plastic sheeting structure. Cubicle large enough for patient plus assistant. Depth 2.5m. Bottom of pit should be 1.5m above water table. Cubicle large enough for patient plus assistant. ≈2.5m2 Plastic squatting slab. Smooth concrete slab. Timber covered in plastic sheeting. Smooth concrete slab. Timber covered in plastic sheeting. Smooth concrete slab. Timber covered in plastic sheeting. Remarks Tents should have hard floors laid in concrete, or timber covered in plastic sheeting. Pit latrines are advisable, as they do not block. Install handrail for weak ambulatory patients. Connect to sewage system or soakaway via grease trap. Connect to sewage system or soakaway via grease trap Connect to soakaway via grease trap. Individual patient compounds for suspect and probable/confirmed patients. Smooth concrete slab. Gravel bed. Allow 2m separations between beds for easy access. ≈10m2/bed Existing buildings. Tent or plastic sheeting structure. Cubicle large enough for patient plus assistant. Depth 2.5m. Bottom of pit should be 1.5m above water table. Cubicle large enough for patient plus assistant. ≈2.5m2 Plastic squatting slab. Smooth concrete slab. Timber covered in plastic sheeting. Smooth concrete slab. Timber covered in plastic sheeting. Good drainage into sewage system or soak away. Must be well ventilated. Tents should have hard floors laid in concrete, or timber covered in plastic sheeting. Probable patient latrines Less than 25m from wards. 1 male, 1 female 1 per 20 patients Probable patient bathing areas Less than 25m from wards. 1 male, 1 female Water points 1 or 2 taps Connect to soakaway via grease trap. Probable patient compound Direct access from probable/confirmed patient accommodation. Open air with shaded areas. Individual patient compounds for suspect and probable/confirmed patients. Connect to sewage system or soakaway via grease trap. 182 Risk Zone Areas & Activities Facility Chlorine preparation Location - Space - Quantity Size Close to water point. Shaded area for preparation and storage of chlorine solutions. Recommended Material & Alternative Material Remarks Smooth concrete slab. Gravel bed. Must have good drainage into sewage system or soak away via grease trap Must be well ventilated. Adapted steel drum and local materials. A chimney can be incorporated to improve burning, and evacuate smoke and fumes at a higher level. Concrete lined pit with roof slab and lockable cover. An adapted steel drum can be used. Once full, or at the end of the epidemic the contents can be encapsulated with concrete and the drum buried. Concrete roof slab with lockable cover. If only small quantities of organic waste are produced, consider using a latrine instead. 2 x 2 x 2.5m with an open drum burner on the top Burner and pit Located in waste zone area Downwind of patient accommodation, laundry, and kitchens, etc. (if possible). Waste Zone See Annex 4.6 Waste Disposal & Pits for further details Sharps pit Located in waste zone area. Volume ≈ 2m3 Organics pit Located in waste zone area. 1.5m x 1.5m Depth 2m 183 Risk Zone Areas & Activities Facility Location - Space - Quantity Recommended Material & Alternative Material Size Remarks 1m 1m 1m Stretcher 2.5x0.9m Easy access from patient areas, separated from patient entrance, access for vehicle. Stretcher 2.5x0.9m VHF Morgue Temporary storage of corpses Stretcher 2.5x0.9m 1m 1m 1.5m Existing building. Tent or plastic sheeting. Must have roof. Must have easily cleaned floor. Sufficient space around stretcher areas to allow easy access, bending and lifting, etc Concrete or gravel floor with footbath of plastic sheeting Should be staffed full time by a guard / sprayer 1.5m 5x7m – 3 stretchers Between Highrisk & Low-risk Disinfection & changing areas Foot bath, hand washing, changing and spraying location 1 between high-risk and low-risk zone Minimum ≈ 3x4m. Size and space required depends on number of staff Foot bath: 80 x 80cm 184 Summary of Facilities in Low-risk Area Risk Zone Areas & activities Between Highrisk & Low-risk Location - Space - Quantity Size Alternative Material Remarks Disinfection & changing areas Foot bath, hand washing, changing and spraying location 1 between high-risk and low-risk zone Minimum ≈ 3x4m. Size and space required depends on number of staff Concrete or gravel floor with footbath of plastic sheeting Should be staffed full time by a guard / sprayer; Disinfection Chlorine preparation Concrete slab Must have good drainage into sewage system or soak away via grease trap Administration Low-risk Zone Recommended Material Facility Foot bath: 80 x 80cm Close to water point. Shaded area for preparation and storage of chlorine solutions. 3 x 4m minimum Doctor’s room 1 room close to the patients area ≈3 x 4m Local building material Must NOT be in High-Risk zone! Laundry washing area Away from burning site, adjacent to laundry lines and water point. Around 9m2 Concrete slab Connect to sewage system or soak away via grease trap Laundry drying area Away from burning site, adjacent to laundry area. Around 15m2 Wooden or iron poles, rope Preferably in the sun, (UV assists in destroying the Ebola virus). 4 m2 Existing building Gravel bed Must be well ventilated. Laundry Area Main entrance. Security Storage Between Low-risk & Outside Treatme nt Unit Disinfection & changing areas Guard shack Every exit from high-risk and low-risk zone. Store room in treatment unit compound 1 small store on compound for several days stock Foot bath, hand washing, changing and spraying location 1 between low-risk and outside treatment unit Tent or plastic sheeting Existing building 3x4m Tent or plastic sheeting Minimum ≈ 3x4m. Size and space required depends on number of staff Concrete or gravel floor with footbath of plastic sheeting Should be staffed full time by a guard / sprayer; Foot bath: ≈ 80 x 80cm Table 6 - Summary of Facilities outside Treatment Unit Risk Zone Areas & activities Recommended Material Facility Location - Space - Quantity Size Alternative Material Remarks 185 General store room 1 outside isolation compound 8 x 4m Kitchen Kitchen for patients & attendants 1 outside the isolation compound 4 x 4m Existing building or plastic sheeting Attendants rest area Resting area Close to exit from treatment unit Depends on number of patients and attendants. Existing building, tent or plastic sheeting Staff room Lunch room and rest area for staff 1 outside isolation compound Staff toilet Latrine 1 per 20 staff 2.5m2 Plastic squatting slab. Smooth concrete slab. On hospital compound Sufficient space for up to 20 persons – classroom seating + demonstration and practice using PPE On hospital compound, close to patients’ entrance. Depends on number of patients Outside Treatment Unit Storage Training Area / Room Relatives area Rest and meeting area for relatives Existing building. Tent or plastic sheeting Existing building, tent or plastic sheeting Must be secure, and constantly accessible. Must be available for patient attendants. Should be a pleasant comfortable space to rest and receive counseling and advice. 186 Annex 4.6 Waste Disposal & Pits Burner and Pit Organic Waste Pit Steel drum Air holes Steel grid Ground level Support beams Min 1.5m above water table 1. 2. 3. 4. Cut top and bottom off drum. Cut air holes in side of drum. Punch holes in side to take steel rods to form grid. Mount on beams over waste pit. Sharps Pit Modified Drum Sharps Storage Drop pipe Lockable hinged cover Ground level Steel drum Discarded sharps containers Drainage Encapsulated sharps containers Minimum 1.5m Water table 1. 2. 3. 4. 5. 6. Cement slurry Cut half of top of drum. Reattach with hinges and fix a lock. Dispose of sharps containers in the drum. When ¼ full, cover contents with cement slurry. Continue to use in same manner until full. Bury the drum in a pit when full or at end of outbreak. Back to Table of Contents 187 Annex 5 Infection Control and Personal Protection Annex 5.1 Barrier Nursing Principles Recommendations to reduce risks and facilitate safe care of patients: Do not work on the treatment unit with an open wound. Avoid working alone: work in pairs or groups. Provide immediate feedback for any lapses in technique or risky practices. Restrict time on the wards to the minimum necessary to accomplish tasks. Minimize direct contact with patients except as necessary. Wash gloved hands in 0.5% chlorine after touching each patient. Ensure that chlorine solutions in dispensers are fresh in the morning before beginning work. Ensure that chlorine solutions in hand washing basins are fresh for each set of rounds. Plan nursing care duties before beginning shift. Ensure all materials necessary for cleaning or disposal of waste are nearby. Paper towels, absorbent pads, waste receptacles, hand sprayer or container with 0.5% chlorine. Immediately disinfect and remove any spills. Have medical equipment to hand for patient rounds, and the means for cleaning items between patients (thermometers, stethoscope, etc.). Always begin work on the suspect case side and move to the probable/confirmed side. Do not return to the suspect case side without disinfecting apron/boots and gloves. Immediately disinfect visibly contaminated protective clothing with 0.5% chlorine. Leave the treatment unit if necessary and remove/disinfect soiled items that cannot be easily disinfected while worn (goggles, mask, cap, and gown). Do not attempt to provide any type of care for which there is insufficient assistance: either ask for help or leave the patient alone until assistance arrives. For example, lifting a patient from the floor; attending to an agitated or disoriented patient; cleaning a bedridden patient who is bleeding or incontinent. Immediately dispose of sharps in the sharps container after use, including needles used in the administration of IV fluids. Do not attempt to give injections or start IV infusions when the lighting is poor, or when patients are uncooperative. Always work with an assistant. Ensure that all infectious waste is promptly disinfected and discarded in the designated area. Avoid administering fluids to a patient in a manner that provokes coughing. If this occurs, stand at least 1 meter away to avoid contamination by droplets. Management of accidental exposure: leave unit immediately and follow guideline displayed in the changing area. See Annex 5.8 Management of Accidental Exposure. 188 Annex 5.2 Dressing & Undressing Protocols Slightly adapted protocols are used for those dressing and undressing outside the Treatment Unit. The main difference being that the reusable materials are disinfected then stored in covered buckets and transported to the treatment unit. Dressing Protocol for Entering the Low-Risk Zone When entering the low-risk zone, staff dress up in the changing room according to the following procedure: 1. Remove street shoes and street clothes. 2. Put on one pair of gloves. 3. Put on scrub suit and your personal rubber boots. Tuck scrub suit into boots. 4. Go into the low-risk zone. Undressing Protocol for Leaving the Low-Risk Zone When leaving the low-risk zone, staff undress in the changing room according to the following procedure: 1. Walk through chlorine footbath and have boots sprayed. 2. Remove boots using boot remover. 3. Remove gloves and dispose into waste bin. 4. Remove scrub suit and place in collection container for disinfection and washing. 5. Put on street shoes and street clothes. 6. Disinfect hands with 0.05% chlorine solution. 7. Spray soles of street shoes with 0.5% chlorine solution when exiting the changing room. Dressing Protocol for Entering the High-Risk Zone Inside the low-risk zone, all staff wear the following: • One pair of gloves. • Scrub suit. • Rubber boots. When entering the high-risk zone, staff dress up in the changing room according to the following procedure: 1. Put on the overalls or gown. 2. Put on a second layer of gloves (can be done after the goggles if using heavy gloves). 3. Put on the mask. 4. Put on the head cover. 5. Put on the apron. 6. Put on the goggles. 7. Go into the high-risk zone. If using hood style head cover: do not tuck shoulder flaps under gown or overall; ensure neck string of apron lies on top of, and secures, the shoulder flaps. Undressing Protocol for Leaving the High-Risk Zone The main principle is that the most contaminated items are removed first. When leaving the high-risk zone, staff undress according to the following procedure: 1. Walk through chlorine footbath. 2. Disinfect apron, boots, and gloved hands with 0.5% chlorine solution. 3. Wash gloved hands with 0.5% chlorine solution. 4. Remove apron, immerse completely in 0.5% chlorine solution, and hang to dry. 189 5. Disinfect outer pair of gloves with 0.5% chlorine solution and remove: a. If using examination / surgical gloves place in waste bin. b. If using household / heavy-duty gloves place in bucket containing 0.5% chlorine solution. 6. Disinfect gloved hands with 0.5% chlorine solution. 7. Remove overalls or gown and place in waste bin. 8. Disinfect gloved hands with 0.5% chlorine solution. 9. Remove goggles, disinfect with 0.5% chlorine solution, rinse in clean water, and hang to dry. 10. Remove head cover and place in waste bin. 11. Disinfect gloved hands with 0.5% chlorine solution. 12. Remove mask and place in waste bin. 13. Disinfect gloves with 0.5% chlorine solution, and remove, place in waste bin. 14. Wash hands with 0.05% chlorine solution. 15. Go into low-risk zone and put on a new pair of gloves. Basic Arrangement for Hand Washing and Disposal of Gloves 190 Example of Undressing Procedure for Leaving the High-Risk Zone 1. Disinfect the outer pair of gloves. 2. Disinfect the apron and the boots. 3. Remove the apron 4. Remove the outer pair of gloves. 5. Disinfect the gloved hands. 6. Remove the outer gown. 7. Disinfect the gloved hands. 8. Remove the goggles. 9. Remove the head cover. 10. Disinfect the gloved hands 11. Remove the mask. 12. Disinfect the gloved hands. 13. Remove the inner pair of gloves. 14. Wash hands with 0.05% chlorine solution, and put on new gloves. 191 Example of Dressing Procedure for Entering the High-Risk Zone (WHO/CDC Manual) 192 Example of Undressing Procedure (WHO/CDC Manual) 193 Annex 5.3 Standard Precautions “Standard precautions” are basic infection control measures, and are a minimum standard in every health structure. “Standard precautions” require that health care workers assume that the blood and body substances of all patients are potential sources of infection, regardless of the diagnosis, or presumed infectious status. 1. Wash hands: Before and after touching a patient. After any contact with body fluids. Prepare soap dish, basin, and container of clean water, waste receptacle, and disposable towel or air-dry hands. 2. Wear gloves: If there is to be contact with body fluids, broken skin or mucous membranes. Remove gloves, discard in waste bucket, and wash hands. 3. Routine cleaning with soap or detergent: Of beds, bedside tables, examination tables. Of floors and latrines. 4. Handle needles and sharps safely: Do not separate needles from syringes. Put needles in puncture resistant sharps container. Do not re-cap needles. Do not re-use needles or syringes. Dispose of sharps container in sharps pit. 5. Safe disposal of spills and waste: Remove with cloth. Wash area with soap and water or detergent or chlorine solution and leave to dry. 6. Wear mask & goggles: The eyes, nose, and mouth are the most vulnerable part of the body; protection is necessary especially if a splash is likely. Additional precautions are necessary for diseases transmitted by air, droplets, and contact. These are termed “additional (transmission-based) precautions”. 194 Annex 5.4 Additional Precautions to Reduce VHF Transmission Precautions to reduce VHF transmission in health structures must be applied in all regular health facilities within the suspected epidemic area as soon as VHF is confirmed. In the VHF Treatment Ward, complete barrier nursing and infection control techniques will be used. Additional precautions required for dealing with VHFs are the following: 1. Isolate the VHF patient: Cover mattress with reusable plastic sheet. Limit patient movement and restrict access to one trained patient attendant. Instruct attendant to avoid touching patient, and provide protective gear and training to attendant. 2. Avoid giving injections or taking blood. 3. Wear protective gear when touching/examining patient 4. Wear mask and goggles especially if splash is anticipated or patient is coughing. 5. Dispose of contaminated materials: Use plastic bag receptacle for contaminated materials such as used latex gloves, or other disposable materials used by patient. Discard and burn contaminated materials. 6. Use disinfection procedures: Prepare 0.5% and 0.05% chlorine solutions. Disinfect the following items in 0.05% chlorine solution: i. Household gloves, aprons, goggles; ii. Medical equipment such as thermometers iii. Cups and dishes Disinfect gloved hands after contact with patient in 0.5% chlorine Disinfect patients excreta, vomit, urine: i. Add 0.5% chlorine to the container to cover contents and discard in latrine. ii. Wash container with soapy water and discard in latrine. iii. Rinse container with 0.5% chlorine (container may then be re-used). Disinfect spills of body fluids i. Cover completely with 0.5% chlorine solution ii. Let stand for 15 minutes. iii. Remove with rag or paper towels. iv. Discard rag in plastic bag for infected waste v. Wash area with soap and water. Disinfect patient clothing and bedding before laundering: i. Soak soiled clothing in 0.05% chlorine for at least 30 minutes. ii. Remove and wash with soapy water, rinse thoroughly and dry on line. 7. Close laboratories and operating theatres to non-essential surgery until safe working is guaranteed. 195 Annex 5.5 Establish Routine Hand Washing ! Hand washing is the simplest and most important precaution for preventing transmission of infections. Washing hands with soap and water eliminates infectious material acquired from contact with blood, body fluids, contaminated surfaces and equipment. Regular hand washing should be routine practice in the health facility even when VHF is not present. Ensure that all health care workers wash their hands: After handling any blood, body fluids, or contaminated items. After/between contact with different patients. After removing gloves. Adequate hand washing requires the minimum of equipment; nevertheless it may be necessary to provide: Cake soap cut into pieces. Soap dishes. o Provide soap dishes with openings that allow water to drain away. Water. o Ideally running water, alternatively a jerry can with tap, or a bucket containing clean water and a long-handled ladle for dipping. Wastewater collection/disposal. o Sink and drain if available, alternatively rinse water should drain into a bucket or basin and then be disposed hygienically. Single-use towels. o Use paper towels, alternatively simple cloth towels used once and then laundered. o Do not share towels. o Air dry hands if towels are not available. The following method can be used if it is necessary to teach hand washing to health care workers: 1. Place a piece of soap in the palm of one hand. 2. Wash the opposite hand and forearm. Rub the surfaces vigorously for at least 10 seconds. Move soap to the opposite hand and repeat. 3. Use clean water to rinse both hands and then the forearms. 4. Dry the hands and forearms with a clean, single-use towel. Dry the hands first, and then the forearms. Alternatively, let hands and forearms air-dry. 196 Annex 5.6 Sharps Control Definition of Sharps Sharps are items that can cause cuts or puncture wounds, including needles, scalpels, knives, infusion sets, saws, broken glass, nails, etc. Avoid Sharps Injuries Limit the use of injections and infusions. Round off the sharp ends of scissors etc. (have them cut by a metal workshop). Remove all glass objects from the Unit; use plastic items. Remove or wrap any sharp objects; protruding nails that could cause injuries, sharp edges on metal beds, wood splinters, etc. Sharps Collection and Storage Reusable needles and syringes are not recommended. Handling of sharps must be reduced to a minimum; most incidents occur when recapping needles. o Recapping of needles must not be done. o Dispose of the uncapped needle directly in a sharps container. Sharps Containers Must be waterproof and puncture-resistant. Must not spill contents if knocked over. Must not be reused. Must be positioned close to where sharps are being used. Must be clearly marked with the word ‘SHARPS’. Should be labelled with the Infectious Substance Symbol. Should have a distinctive colour - preferable yellow. The standard MSF cardboard sharp containers are not recommended as they become weak in a wet environment and can be punctured. Sharps Transport Sharps should be disposed of close to the location where they are produced; within the Treatment Unit. Do not allow sharps to be transported to a central collection point as monitoring of transport and disposal is difficult. Sharps Disposal Do not try to burn or incinerate needles and sharps. Dispose of containers in a specially built sharps pit, alternatively store and encapsulate containers in a modified drum, and bury once full. 197 Annex 5.7 Checklist for Patient Items Provided at Admission Each patient admitted to the Treatment Unit must be provided with the following items. Patient Items Provided at Admission Quantity Item 1 1 Mattress covered with heavy-duty plastic sheeting. 2 1 Bed sheet and/or blanket. 3 1 Blue basin for bathing and laundry. 4 1 Red bucket with lid for collecting liquid waste (vomit, spills, etc.). 5 1 Green bucket with lid for laundry. 6 1 Plastic plate. 7 1 Spoon. 8 1 Large plastic cup for drinking. 9 1 Yellow jerry can of 5l for drinking water or ORS. 10 1 Roll of paper towel. 11 1 Bar of soap. 12 5 Absorbent pads 13 14 15 Modify the checklist according to the context. Additional item for probable/confirmed cases. Plastic bag for collecting empty IV fluid bags as a record of IV fluid intake. Suspend bag on end of the bed. This bag must not be used for rubbish, needles, or sharps. 198 Annex 5.8 Management of Accidental Exposure ! The main objective is to react appropriately and minimise the risk of infection. Definition of Exposure Needle-stick injury. Other puncture, laceration or abrasion caused by potentially contaminated object. Unprotected contact with patient’s body or body fluids, or other potentially contaminated material. Procedure Do not panic! Try to remain calm and follow the steps below. Needle stick injury, or other puncture, laceration or abrasion injury caused by sharp, potentially contaminated object. Immediately immerse the exposed site in 70% alcohol for 30 sec or 0.5% chlorine solution for 3 minutes. Thoroughly wash affected area with soap and clean water. Flush with clean running water for 30 seconds. Apply dressing if required. Take HIV Post Exposure Prophylaxis (PEP) if advised. Check temperature daily for 21 days. Unprotected contact with VHF patient’s body or body fluids, or other contaminated material. Contact with the eyes: o Immediately flush the affected eye with copious amounts of clean water, ringer lactate or sodium fluid. Contact with the mouth or nose: o Immediately rinse the mouth or nose with 0.05% chlorine solution. Do not swallow the chlorine solution. o Rinse mouth or nose thoroughly with clean water Contact with broken skin: o Rinse the affected area with 0.5% chlorine solution. o Thoroughly wash the affected area with soap and clean water Report the incident to the Supervisor of the Treatment Unit or Doctor in Charge. Notes: Consider exposed person as contact, check temperature daily and follow up for 21 days. Finally, identify the cause of the accident in order to take corrective action and prevent future accidents. 199 Annex 5.9 Waste Management Waste Definitions, Collection, Transport, and Disposal Type of Waste Burnable waste Definition and Examples Collection Transport Dry waste is all waste that has low moisture content and is therefore easily burnt. Examples are dressings, packaging, paper, used protective clothing (gowns, gloves, etc), etc. To reduce the risk of leaks, 2 bags, one inside the other, should be used to collect both wet and dry waste. The waste worker must promptly transport the bag(s) to the waste area. Wet waste is waste that has high moisture content. In practice, mainly contaminated waste that has been disinfected with chlorine (clothes, mattresses, etc). Examples are body fluids: vomit, soft stools, urine, blood, etc). Body fluids can be excreted in two ways: Liquid waste 1. In a controlled way (into a bucket); 2. In an uncontrolled way (spills on floor, bed, clothes, etc). Burnable waste is collected in doubled plastic garbage bags. The bags should be supported in a garbage-bagholder. When the double bag is ¾ full, collect it and close with a string or tape. Disinfect the outer bag. Put new double bags in the bin immediately. 3. Controlled: Collect waste in a bucket with 2cm of 0.5% chlorine solution. When waste has been excreted, add enough 0.5% solution to cover completely the waste Allow minimum of 15 minutes for chlorine to act. 4. Uncontrolled spills: Pour 0.5% solution directly on the spill without splashing. Leave for 15 minutes. Mop up with an absorptive pad or towel. Place the waste into a bucket. Organic waste originating from the human body is a huge biohazard and must be disposed of immediately. Organic waste Organic waste originating from the human body: placentas, body parts, etc. Other organic waste e.g. food leftovers. Sharps Items that can cause cuts or puncture wounds, including needles, scalpels, knives, infusion sets, saws, broken glass, nails, etc. Sharps containers must be – waterproof, puncture resistant, and clearly marked “SHARPS”. Run off water: rainwater from the roof, or compound. Avoid that run off water flows out of higher risk into lower risk areas. Wastewater: water used for cleaning, from foot baths, used chlorine solutions, etc. Wastewater must be channelled to, and disposed of in a soak away. Waste water Organic waste can be collected in a double plastic bag or bucket. Close the bags with a string or tape. Disinfect the outside of the bag or bucket. The bag(s) can be carried in a wheelbarrow to reduce the risk of the bag splitting and possible contamination of the compound. Transport the covered bucket to the latrine without splashing or spilling. Disposal Bags must be burned without opening them. Assist burning with paraffin or diesel as necessary. Liquid waste can be disposed of into a special liquid waste pit or into a pit latrine. The soaked pads should be disposed of into a pit latrine (never into a flush toilet!), or into the waste pit / burning pit. The bags or buckets must be taken immediately to the waste zone. Organic waste can be disposed of in a specially built organic waste pit or if not available, a pit latrine can be used. Disinfect outside of the sharps container before transporting. Sharps pit. Direct run off water and wastewater to separate gutters, ideally lined with concrete or cement mortar. Run off water and wastewater has to be controlled and directed to safe disposal areas. If wastewater is disposed of in a soak away, a grease trap should be installed. The grease trap must be thoroughly disinfected before cleaning. 200 Annex 5.10 Preparation of Chlorine Solutions Two chlorine solutions are used: 0.5% and 0.05%. Instructions are given below on how to prepare the solutions using HTH granules with 6570% active chlorine. Guidance is also given on the use of other products. The safety precautions necessary when handling chlorine products and solutions are also described. CAUTION! Chlorine is a very aggressive and corrosive chemical. Always wear protective clothing (gloves, apron, mask, eye protection) when handling chlorine granules and strong solutions. Prepare chlorine solutions in a well-ventilated area, preferably in the open air. Use plastic containers and equipment for the preparation and storage of chlorine solutions. Preparing 0.5% and 0.05% Solutions with HTH-70% Chlorine Granules Typically, large volumes of chlorine solutions must be prepared every day. Therefore, simplicity, ease, and convenience take precedence over trying to prepare a solution of precisely 0.5% or 0.05%. To this end, the following table gives the quantities of HTH required for the various volumes of the containers found in the kit. (The resulting solutions are slightly stronger than 0.5% and 0.05%) Volume 0.5% 10l bucket 5 spoons* 20l bucket 10 spoons* 60l (half 120l container) 1 x 500g pot 120l container 2 x 500g pot *Spoons are those found in the kit or soupspoon sized 0.05% ½ spoon* 1 spoon* 3 spoons* 6 spoons* Preparation 1. Fill the container with clean water. 2. Pour in the required amount of HTH and stir well. 3. Allow the white sludge to settle and use the resultant clear liquid. 4. Every time the container is refilled, the white sludge should be discarded into a soak away or sewer. Preparing Solutions with NaDCC Tablets (1.5g active chlorine) The 1.5g tablets can be used for preparing small quantities of solutions. Volume 0.5% 0.05% 10l bucket 35 tablets 3.5 tablets 20l bucket 28 tablets 7 tablets Storage Chlorine products and solutions are weakened through exposure to air, sunlight, and heat. Store products and solutions in closed plastic or plastic lined containers. Store products and solutions in a cool, shaded (ideally dark) area. Other Products HTH is the recommended chlorine product to use as it is very stable and the percentage strength is not affected as readily as with other products. However, in certain circumstances it may be necessary to use products other than HTH-70% for the 201 preparation of chlorine solutions. However, the percentage strength of the product must be known. This can be tested at a lab or If relying on the manufacturers factory design strength then: o The products must be no older than 3 months. o The storage and transportation history of the product should be known. Once the percentage strength of the chlorine product is known, the following formula can be used to calculate the dilution proportions for preparing the chlorine solutions. solutionstrength required(%) volume required(l) product strength (%) Quantity of chlorine product (g) 10 100 For example, to prepare 120l of 0.5% solution with household bleach at 4% strength 100 0.5 (%) 120 (l) Quantity of household bleach (g) 10 4 (%) 10 25 0.5 120 15000g or 15 litres of household bleach Precautions Always wear rubber boots, an apron, and gloves when handling 0.5% solution. Try not to splash. Be very careful with eyes and skin since the solution is very aggressive. When applied on metal objects (cars, etc) rinse at least 3 times with clean water. Solution should not be kept more then 24 hours. If solution is more than one day old, dispose of it in a soakaway or latrine. Annex 5.11 Maintaining Chlorine Sprayers The sprayers used for chlorine solutions must be maintained regularly. Some parts of the sprayers are metallic and corrode when in contact with chlorine solutions. The calcium in the HTH granules can solidify and block the pipes and fittings. Procedure Empty the sprayer of any remaining chlorine solution. Rinse with clean water (spray some clean water to rinse the inside of the pipes). Empty out the water. Dismantle the main parts of the sprayer – pipes, nozzles, etc. Put all small parts in a container of pure vinegar, leave to soak for 5 minutes then brush with a toothbrush. Fill 1/3 of the reservoir with clean water; add 1l of vinegar, shake, and leave to soak for 15 minutes. Check sprayer parts and fittings for damage, and repair as required. Reassemble the sprayer; spray the vinegar solution on all outside parts to remove any calcification. Empty any remaining vinegar solution. Rinse with clean water (spray some clean water to rinse the inside of the pipes). Refill with chlorine solution. 202 Frequency Rinse every 2 days using plain water Clean once per week with vinegar as described. Material Required Clean water. Vinegar. Tooth brush. Small plastic container. 203 Annex 5.12 Transferring Material Into & Out of the Treatment Unit General Principles Material and equipment entering and belonging to the high-risk zone should not leave it. However, some items do need to be transferred in and out of the treatment unit. Buckets, potties, plates, bed covers, blankets, and sheets All these items are identified as belonging to the high-risk zone and they must not leave it. Food All plates, cups, cutlery, etc are provided for the patients inside the isolation ward; there is therefore no need to bring extra plates, cups etc. from outside. The food being provided by MSF will be brought to the treatment unit in suitable containers: One identified person collects the food and brings it to an identified transfer area of the fence separating the high-risk and the low-risk zone. A nurse inside the high-risk zone is responsible to collect the food in a suitable container. The food is tipped from the “outside” container into the other. Neither the containers nor the staff performing transfer of the food should come into physical contact with each other. Family members who bring food to the treatment ward should be advised to bring it in plastic bags or do the "tipping" system. Personal items Bringing personal items into the treatment ward should be discouraged. Only items that can be reliably disinfected should be allowed to leave the area, after ensuring adequate disinfection. Clothes of deceased patient: burn in the treatment unit Plastic items, plates, cups, jerry cans, etc. can be cleaned and disinfected: o Bring the item close to the patient exit door. o A "clean" staff member (someone who has just entered the treatment ward and who is not contaminated) should handle the disinfection and handing over of the item. o Disinfect the item by spraying with 0.5% chlorine solution. o Wash hands with 0.5% chlorine solution. o Drop item over the fence or hand over to patient leaving. Gloves and aprons Disinfected items can only be taken out of the high-risk zone, if: Disinfected with 0.5% chlorine solution. One person in the low-risk zone brings an empty bucket to the fence separating the high-risk and low-risk zone Cleaner from high-risk zone bring gloves and aprons in a bucket with fresh 0.5% chlorine solution. The items are tipped over the fence into the other bucket. Neither the containers nor the staff performing the transfer should come into physical contact with each other. 204 Annex 5.13 Cleaning & Disinfection of Protective Equipment Items that require routine and regular disinfection, cleaning and/or laundry are: Aprons Goggles Scrub suits Boots Reusable Gloves Disinfection of Aprons Spray apron before removal with 0.5% chlorine solution. Dip in bucket of 0.5% chlorine solution for 3 minutes and then scrub. Dip in bucket of fresh 0.5% chlorine solution. Rinse with clean water. Hang to dry. The apron could be left for a longer period in the chlorine solution if particularly dirty, but do not leave to soak for too long to avoid damaging the apron. Disinfection of Goggles Place goggles under a flow of 0.5% chlorine solution for a few seconds, and ensure that all parts of the goggles have been soaked in the solution. Rinse with clear water Hang to dry, preferably in the sun. ! Always rinse goggles with clean, fresh water. Each user is responsible for ensuring that their goggles are disinfected and clean before putting them on. Disinfection of Scrub Suits and Laundry Put scrub suits in fresh 0.05% chlorine solution. Leave to soak for 30 minutes. Rinse twice with clear water. Wash with detergent and fresh water. Rinse with clear water. Hang to dry in the sun. Cleaning and Disinfection of Boots Put boots in fresh 0.05% chlorine solution. Leave to soak for 30 minutes. Rinse twice with clear water. Dry upside down on sticks driven into the ground. Should be done once per week (on person’s day off) Drying Boots on Sticks Driven into the Ground 205 Disinfection of Reusable Gloves Household gloves and heavy-duty gloves can be reused after disinfection and cleaning. Soak in 0.05% chlorine solution for 30 minutes. Rinse twice with clean water. Fill gloves with water and squeeze to check for any leaks. Dry on sloping racks or on sticks driven into the ground. Must be done after every use. Glove Drying and Storage Rack 206 Annex 5.14 Infection Control Checklist for VHF Treatment Unit Date: ___________ Time: ___________ Checked by: ___________ To be Verified Yes No Comment Staff Entrance & Changing Room 1 Entrance area clean & tidy Changing room(s) organised and clean Waste bins not overflowing All waste disposed correctly Adequate stock of protective clothing Containers for used scrub suits not overflowing All dirty scrub suits in containers Guard / spray man present Sprayer and hand washing containers filled with correct chlorine solution Changing room 2 (low-risk to high-risk) Changing area organised and clean Waste bins not overflowing All waste disposed correctly Adequate stock of protective equipment Reusable equipment disinfected correctly Goggles, aprons, etc. stored correctly Used protective clothing in ‘dirty’ area only Guard / spray man present Sprayers and hand washing containers filled with appropriate chlorine solutions Foot baths contain 0.5% chlorine solution Foot baths relatively clean Foot baths refreshed at 9am Foot baths refreshed at 4pm When leaving High-Risk zone the correct disinfection, and PPE removal procedures are followed. Chlorine Preparation Adequate quantities of solutions available at all times Chlorine making areas clean and organised Correct method of preparation & strength of 0.5% solutions Correct method of preparation & strength of 0.05% solutions Laundry 207 To be Verified Laundry areas clean and organised Patients’ clothes, blankets soaked in 0.05% overnight in the High-risk area. Collection and transport of laundry according to regulations. Staff scrub suits soaked for minimum 1 hour in 0.05% solution Yes No Comment Laundry lines cleared of dried laundry Laundered items returned to appropriate place. Waste Management No full waste bins present No accumulation of littered waste in any areas of unit Burnable waste is collected and transported in plastic bags. Liquid waste collected and transported in covered plastic buckets. Sharp waste collected and transported in sharps boxes. All waste is disposed correctly. Waste is burnt properly. Protective Clothing People in Low-Risk zone wear scrub suits, boots and gloves People in High-Risk zone wear full protection People leaving the treatment unit remove all protective clothing All protective clothing disinfected and removed according to protocols Back to Table of Contents 208 Annex 6 Medical Treatment Annex 6.1 Example Treatment Protocol for VHF AGE / WEIGHT < 1 year 1 – 5 years 5 – 15 years Adults Dose adults Total TAB/ p / 7 days Dose adults Total TAB/ 10 p/ 7days TREATMENT MEDICATION 4-8 kg 8 – 15 kg 15 – 35 kg > 35 kg Antibiotics for secondary infections Cotrimoxazole 480mg x 5 days ¼ cp. 12/12 h. ½ cp. 12/12 h. 1 tab 12/12 h. 2 tab 12/12 h. 28 tab 280 tab ½-¾ cp. /day/3 days ¾ cp./day/3 days 4 tab/day/3 days 12 tab 120 tab Antimalarials Artesunate 50mg + Amodiaquine 200mg 3 tab/day/3 days 9 tab 90 tab ½ cp./day/3 days ORS ml / day 400 – 600 ml Paracetamol 100mg ½-1 tab 8/8 h Rehydration *Fever/Pains Paracetamol 500mg ¾ cp./day/3 days 1½-2 tab/day/ 3 days 1–1½ tab/day/ 3 days 600 – 1200 ml 1200 – 2200 ml 2200 – 4000 ml 28 packs 280 packs 1-2 tab 8/8 h. ½-1½tab 8/8 h. 1 – 2 tab 8/8 h. 42 tab 420 tab 42 tab 420 tab 1tab 12/12 h. 21 tab 210 tab 1 – 2 tab 6/6 h 56 tab 560 tab ¼-½ tab 8/8 h. *Nausea / vomiting Promethazine (25mg) *Severe pain Tramadol 50mg *Abdominal pain / Distension Cimetidine (200mg) 1/8 tab 6/6 h. ¼ tab 6/6 h. ½ tab .6/6 h. 2 tab 6/6 h 56 tab 560 tab Vitamin deficiency Vitamin A 200,000 IU X 1 tab single dose 1 tab single dose 1 tab single dose 1 tab 10 tab Vitamin deficiency Vitamin B 1 tab/day 1 tab/day 1 tab/day 1 tab/day 7 tab 70 tab Vitamin deficiency Vitamin C 1 tab/day 1 tab/day 1 tab/day 2 tab/day 14 tab 140 tab ¼ tab 12/12 h. ½ tab 12/12 h. * Only if the patient has symptoms 209 Annex 6.2 Systematic Treatment Protocol The systematic treatment protocols are designed to make the management of VHF patients easier in an African field setting. As normal laboratories are not equipped to allow the processing of samples from VHF patients, there are likely to be few tests available for use on these patients. This makes common diseases like malaria and typhoid more difficult to diagnose and/or rule out. Antibiotics and antimalarials will be of therapeutic use to patients presenting with infections other than VHF, but also rapid response to these medicines may aid in an alternative diagnosis and facilitate in their discharge from the isolation ward. Depending on the dynamics of the outbreak, a significant number of patients in the isolation ward may have curable infections. Patients with VHF may also have concurrent infections with common diseases that can interfere with their ability to mount a response to the VHF infection. Systematic treatment with appropriate antibiotics and/or antimalarials should be considered in each patient. At any stage in a person’s illness, other treatments can be given if other diagnoses are thought possible, although the risk of side effects of over-medication must be considered. The protocols include treatment for some common conditions and symptoms. They cannot replace the clinician’s experience; therefore, they should be used flexibly. They can be especially useful for home-care patients in remote settings, where regular medical follow up is not possible. Treatments ACT for malaria. A commonly used regime is 3 days of daily artesunate and amodiaquine. Give this to all patients on admission. Broad Spectrum Antibiotics. Give 5 days of broad-spectrum antibiotics to all patients on admission. Co-trimoxazole or Cefixime are appropriate. Paracetamol. This is generally only recommended for the first days after admission as a systematic treatment, in order that fevers are not masked later. After the first 1-3 days, paracetamol should be given to patients with pain or fever. Cimetidine. Give Cimetidine, ranitidine, or proton pump inhibitors to all adults regularly. PPIs may cause more side effects. This is for prophylaxis against dyspepsia, which is very common in VHF patients. Anti-emetics. Give these to all adults regularly, as nausea and vomiting are extremely common. Malaria treatment and typical doses are given in Annex 6.3 Malaria Treatment during VHF Outbreaks. A sample prescription form for systematic treatment is given in Annex 12.5 VHF Treatment Sheet. See MSF clinical guidelines (on the CD) for treatment of specific infections. Annex 6.3 Malaria Treatment during VHF Outbreaks See notes below for important information concerning these protocols. In many countries during the malaria season, a high (>70%) Paracheck positivity rate can be expected. However, a positive Paracheck will not rule out a VHF case. 210 Objectives To identify and treat malaria patients. To offer the most efficient treatment in order to avoid relapses and avoidable fever. To avoid unnecessary referral of patients to the isolation/triage wards. To quickly identify and refer suspected VHF cases. To decrease the use of sharps and to reduce the amount of waste to be handled. Case management Treatment must be ACT. In Regions with No Suspect VHF Cases Perform a Paracheck test to confirm the clinical diagnosis, and treat orally with ACT. If oral treatment is not possible, treat with injectable artemether or quinine according to the current protocol. In Regions Where There Have Been Suspect VHF Cases DO NOT PERFORM PARACHECK. Assess patient according to case definitions for VHF patients. o If the patient is a suspect or probable VHF case: Refer to triage unit, where patient will be treated with oral ACT, and followed as a VHF case until proven negative. o If the patient is not considered as a suspect or probable VHF case: Give presumptive oral ACT. For both situations, if the patient is unable to take oral medication: Give rectocaps AS and continue with oral AS+AQ asap (usually the 2 nd day), giving the full 3-day course with AS+AQ If the patient has severe malaria, and is unable to take oral treatment, continue with the same dose of rectal AS daily until the patient is able to take oral treatment. Then give the full 3-day course of ACT (AS+AQ) If artesunate rectocaps are not available, intrarectal quinine can be used to start the treatment followed orally with 3-day course of AS+AQ. Do not use artemether intrarectal. Ask non-VHF suspect patient to return the next day for follow-up, and again the following day if no improvement. Refer if no improvement within 48 hrs, or if the patient develops symptoms compatible with VHF diagnosis (suspected or probable). Treatment Protocols with Artesunate Rectocaps The following dosing schedule was developed for artesunate rectocaps in order to reach an average concentration of 10 mg/kg. Weight Number of Age in kg caps Dose in mg 4 - 10 months 4-7 1 x 50 50 10 – 18 months 8 - 12 2 x 50 100 18 months – 3 yrs 13 - 17 3 x 50 150 4 - 8 yrs 18 - 25 1 x 200 200 > 8 yrs 26 - 55 2 x 200 400 Single dose, treatment to continue with oral AS+AQ Maximum mg/kg 12.5 12.5 11.5 11.1 15.0 Minimum mg/kg 7.0 8.3 8.8 8.0 7.2 211 If expelled within 30 min, a second dose should be given. Notes Concerning Those Protocols Use of Artesunate Rectocaps This protocol was developed for use during the Marburg outbreak in Angola 2005. Information on the stability of artesunate rectocaps manufactured by Mepha was not available, so it was unclear how the finished product behaves after leaving the factory. The systematic use of artesunate rectocaps was not approved by MSF. Given the prevailing situation at the time, the Medical Directors approved the exceptional use of artesunate rectocaps. In the region where the Marburg outbreak was present, it was considered less risky to use artesunate rectocaps than to use injections. It was agreed that a limited stock could be ordered and kept under strict supervision. With all the unused doses being destroyed or brought back to Europe at the end of the outbreak. This situation may have changed; check with medical coordinators/advisors for current recommendations. Policy on Confirmed Malaria Diagnosis The need to confirm malaria diagnosis systematically is confirmed. However, in VHF outbreak situations, considering the benefit of confirming the diagnosis and the risks linked to VHF transmission, the medical directors accepted the treatment of malaria without confirmed diagnosis. This exceptional approach should stop as soon as the outbreak is over. 212 Annex 6.4 Maternity and Delivery Guidance Deliveries with Fever Induction of labour: use Misoprostol tablets (25-50μg sublingually), this may be repeated if no effect. Do not use Ocytocine injections. Third stage: use Misoprostol (600μg sublingually). Do not use Ergometrine or Ocytocine injections. Episiotomy indication: only in very special cases. Prevent and treat post-partum haemorrhage using Misoprostol tablets either sublingually or rectally after placental delivery. Do not use Ocytocine injections or infusions. In case of instrumental extraction, use vacuum extractor; do not use forceps. Incomplete abortion: avoid curettage. Use Misoprostol tablets (800μg sublingually) in case of 8 weeks of gestation, may be repeated after 6-12 hours. In case of antenatal haemorrhage verify that the haemorrhage is caused by obstetric causes, and CS only if maternal indication. In case of dystocia, do PCR first and only proceed to CS if life threatening to mother. Caesarean Section Caesarean indication: only in very urgent cases linked with vital maternal prognostic (e.g. uterine rupture, transverse presentation) and not foetal indication. Caesarean section: use midline incision. Do not use Misgav-Ladach or other techniques requiring a large transverse incision; they are more traumatic and time consuming. Do not close peritoneum. Haemostatic closure of lower segment transverse incision, possibly in one layer. Cutaneous closure using staples (agrafes), if available. Order from international catalogues. Back to Table of Contents 213 Annex 7 Data Collection & Operational Research As mentioned in the main text, there is limited information and knowledge about Ebola and Marburg especially in relation to clinical treatments and their effects on patient outcomes. Therefore it is important to rigorously collect data and evidence that can demonstrate the benefits (or potential harm) of the various treatments, therapies, and approaches that are used. The collection and analysis of information should focus on symptoms, treatments, and outcomes. This information will be valuable for furthering the understanding of the diseases, and for improving the response in future outbreaks. The collection and analysis of data must conform to ethical norms. Patient confidentiality must be assured. Information and data must be collected and recorded accurately so that any eventual findings and conclusions are valid. Any changes to case definitions, methods of collecting information, etc. must be clearly recorded to avoid errors or confusion when presenting and analysing the data collected. The existing data collection forms in Annex 12 Medical and Epidemiological Forms facilitate the collection and analysis of patient data. The information collected using the Medical Admission Form, Observation Sheet, and VHF Treatment Sheet can be used to develop a clinical description for each patient during the time they are under observation. The following information should be compiled. Patient information and demographic data. Clinical information at presentation and admission. Development and progression of symptoms through the time of the illness. Therapies and medications administered at different stages of the illness. Information gathered from subsequent patient follow-up activities can also be incorporated to analyse factors arising during the convalescence period. The analysis of the effects of therapies and medication provided can then be done. New therapies and treatments are being researched and developed, and these may prove useful in the prevention or treatment of Ebola and Marburg. However, considering the high case fatality ratios, using conventional methods and approaches to trials of these therapies may be difficult. For example, allocating patients to an untreated control group in a randomised clinical trial during an outbreak would be unethical. An alternative is to consider that the patients treated now and in the past may act as historical controls for future trials. At the minimum, this requires the collection of good baseline data and the development of thorough clinical descriptions of the evolution and outcome of the disease in all patients. Other data pertinent to therapies in development could also be collected as long as this did not negatively affect the normal outbreak control activities. The nature of the therapies being developed will determine the type of data that would be required for this purpose, therefore clear understandings, agreements and coordination with the research institutes, WHO, and local and international health authorities will be essential. Specific data collection forms can be compiled to simplify the collection of detailed data required for particular research and analysis. 214 Annex 8 Health Centre Outreach and Assessment Activities Annex 8.1 Outreach Guideline: Health Centres Outreach activities are a component of case management and should be instituted at the onset of the intervention. The aim is to ensure that health centres can safely deal with any suspect VHF cases that may come to the health centre. Training, supervision, and followup are essential and must be in accordance with identified needs. One of the primary objectives is to assess the capacity of health centre personnel to recognise, hold, and refer a suspect VHF case. However, it is clear that the capacity of most health facilities is too limited to provide appropriate isolation for more than a few hours. Therefore, the focus should be directed at reinforcing standard and additional precautions, safe waste disposal along with prompt referral of suspect case to an established Treatment Unit. MSF should be prepared to assist health centres in improving facilities, skills, and understanding of VHF case management to achieve minimum standards necessary to reduce risks to the staff and to other patients. Priorities to Guide Selection of Health Centres Those serving the areas from which cases are being referred: begin with those with the largest number of cases. Those located in areas where travel and transport is restricted due to insecurity or difficult terrain. Those serving areas adjacent to or having important population interaction with affected areas. Objectives Ensure that health personnel can recognise, safely accommodate, and refer a suspect case to an appropriate Treatment Unit. Implement basic procedures for safe disposal of sharps and medical waste. Implement basic procedures for disinfection of contaminated articles, and disposal of contaminated waste. Ensure the availability of materials/supplies to implement standard and additional precautions, and appropriate waste disposal procedures. Establish procedures for communication and transport of suspect cases to Treatment Unit. Activities Evaluate level of knowledge of VHFs: case definitions, transmission, and prevention of infection. Evaluate capacity to recognise, accommodate, and refer suspect cases to the Treatment Unit. Evaluate knowledge and practice of standard precautions. Assess water, hygiene, and sanitation facilities. 1. Water storage capacity: ideally 50 litres per person per day. 2. Excreta disposal: a. Easily cleaned latrine floor. b. Availability of anal cleansing material. c. Convenient hand washing facility with soap. d. Buckets for excreta collection and disposal for suspect case in holding area. 3. Waste disposal: 215 a. 5 plastic waste bags. b. Waste pit (1 x 1 x 1 meter size). 4. Burial of deceased: a. Burial site identified. b. Burial team identified, trained, and available. c. Burial team supplied with stretcher. d. Availability of full protective clothing (boots, aprons, gowns, goggles, masks, latex and household gloves) and 12 litre sprayer with 0.5% chlorine solution. Identify a holding (isolation) area and implement disinfection procedures, and safe disposal of waste for this area. Provide basic protection and disinfection materials. Deliver Training Module for Health Centre Staff to health care workers and support staff. Provide training, supervision, and follow-up according to needs identified during the initial assessment. Annex 8.2 Assessment Team Guideline The assessment team evaluates the presence of new VHF cases reported from outside the area of an identified ongoing epidemic. The basic principles are also applicable to an initial outbreak investigation. The composition of the team and the procedures for performing an assessment will vary depending on the availability of laboratory confirmation and the national and international organisations involved in the response. Objective Assess the presence of suspect cases Assess and assist in the implementation of an isolation area. Monitor the set up of a surveillance system and community mobilisation. Assist in the formation of a task force in collaboration with WHO, MoH, district authorities, etc. Indications for Performing an Assessment Immediately after clinical identification or laboratory confirmation of a case coming from a district outside the outbreak area. Presence of a suspect case coming from outside the outbreak area with contact history in accordance with case definition. Composition and Roles of Assessment Team MSF: one medical (case management) and one watsan (isolation, infection control, etc.). WHO: general coordination and organisation of district task force and technical group. MoH: surveillance, and community mobilization. Communication Initially, contact by phone (if possible) should be established with MoH and Medical Officer of the affected district. MSF/WHO remains in close contact with appropriate laboratory with regard to results of samples. MSF assessment team coordinated by outbreak control team coordination. Logistics 216 Transport: MSF should be prepared to transport the complete team for the first assessment. Strategy Set up an isolation area designed to hold 2 cases for a maximum of 3 days. Provide necessary training to personnel/support staff to ensure the safe operation of isolation area. Ensure that adequate supervision is continuously present. Provide materials and supplies contained in the Assessment Kit that will ensure the functioning of the isolation area for 3 days (see Annex # Assessment Kit). Modify the contents of the kit in the context of the outbreak and logistical constraints. Re-evaluate additional needs as determined by the evolution of the outbreak 1. 2. 3. 4. 5. 6. 7. 8. Assessment Activity Check List Present the team, their credentials, and the objectives of the visit to local, district, and regional authorities. Meet with and coordinate plans and activities with District Task Force and Technical Task Force counterparts (if existing). Obtain background and current information with regard to the following: Number of cases, suspects, and contacts. Location and movements of cases, suspects, and contacts. Dates of cases, and contacts. Initial responses undertaken by health authorities. Attitude and response of the affected population. Status of health promotion and community mobilisation efforts and materials used. Evaluate site for possible isolation facility: Ease of access for transport. Water supplies. Health facility waste disposal arrangements. Excreta disposal facilities. Electricity supplies. Suitability of available buildings. Evaluate needs: Protective material. Water and sanitation equipment. Rehabilitation inputs required. Availability of qualified health staff and of support staff. Availability of ambulance transport. Feasibility of transfer of patients to an existing Treatment Unit. Identify safe and reliable mechanisms to transport additional blood specimens as required. Training materials package: Training Module for Health Centres. Case definitions. Standard and additional VHF precautions. Preparation of chlorine solutions and specific uses of each solution. Use of protective clothing. CDC/WHO and MSF publications dealing with VHF outbreak control. Provide feedback to appropriate authorities and make recommendations. 217 Annex 9 Home Based Support and Risk Reduction Annex 9.1 Implementation of Home Based Support and Risk Reduction The best approach to containing an epidemic of Ebola or Marburg haemorrhagic fever is to isolate the patients in a VHF Treatment ward. A well functioning VHF Treatment ward allows care to be provided in a safe environment; contributes towards breaking the transmission routes; and provides protection for the patients, their families and the community. However, if the family refuses categorically to bring the patient to the VHF Treatment ward, an alternative approach must be considered even if that alternative is less than perfect. Home Based Support and Risk Reduction is an alternative approach where the patient remains at home, and is looked after by his/her family. Protective equipment and disinfection materials are provided, training is given, and a daily follow-up by a mobile team is organised. 1. The suspect patient is identified but refuses to be admitted in the VHF Treatment ward. a) The MSF staff will try to convince the patient to be admitted in the ward. b) If the patient still refuses, the option of Home Based Support is offered. 2. One single person of the family is identified as a caretaker. a) The caretaker is trained and provided with protection equipment and disinfection material. b) The caretaker will be invited to make a visit to the VHF Treatment ward. 3. In the family compound, identify an independent room with a separate entrance to isolate the patient. Remove any unnecessary furniture, furnishings, and other belongings. 4. Dig a 1m deep pit for the caretaker to burn the waste. 5. If possible, identify a latrine to be used only for the patient. Otherwise, instruct the caretaker to make the family latrine inaccessible to the patient and provide him with a potty filled with 1cm of chlorine solution. 6. Explain to the caretaker how to: a) Give the drugs to the patient. b) Feed and wash the patient. c) Disinfect and dispose of faeces and any spills. d) Disinfect and wash clothing, the bed and bedding, etc. 7. Ensure that the patient has his own utensils: cup, plate, and spoon. 8. Cover the mattress with the plastic sheeting. 9. Ensure that all materials (jerry cans, sheeting, potty, etc) are put in place correctly. Install everything together with the caretaker; both persons will be dressed with protecting clothing. 10. Arrange times to visit the home and make a daily follow. The follow-up should be done at times when the caretaker is caring for the patient. Composition of the team doing the training and follow-up: One medical. One cultural translator. One watsan. One psychologist or health promoter. One community-based public health technician. After the initial training visit, the psychologist/health promoter and the watsan can rotate. 218 Material and equipment to be provided: Protective clothing Plastic sheeting Jerry cans for preparation an storage of chlorine solutions Pre-measured doses of HTH 70% granules Plastic bottle for preparation and storage of ORS. Plastic buckets and bowl Absorbent pads Soap Rubbish bags 219 Annex 9.2 Caretaker Task Instructions Dressing and Undressing The caretaker dresses up outside under supervision. o Order: shoe covers then gown, then mask, then gloves, then apron, and then goggles. The caretaker undresses outside at the door under supervision. Order: o Wash hands with 0.5% chlorine solution, o Disinfect the apron, remove it and place it in the bucket containing 0.5% solution o Take off the shoe cover and place it in the rubbish bag. o Wash hands with 0.5% chlorine solution o Take off the gown and place it in the rubbish bag. o Take off the goggles and place in the bucket containing 0.5% chlorine solution. o Take off the facemask and place it in the rubbish bag. o Wash hands with 0.5% chlorine solution. o Take off the gloves and place them in the bucket containing 0.5% chlorine solution. o Wash hands with 0.05% chlorine solution. Give the Drugs Give the drugs according to the timing written on the prepared drug bags. The systematic treatment is the same as that provided in the VHF Treatment ward. Ensure that the patient takes all the pills. If the patient cannot swallow, crush the pills and mix with some liquid. It is forbidden to give injections, IV treatment, or traditional medicines. Provide the Food Ask the patient to bring his plate to the door and spoon the food into it without touching. If the patient cannot walk, the caretaker dresses and enters the room, and brings the plate to the door where another family member spoons the food into it without touching. Wash the Clothes and Utensils Before entering the room, put a bucket half filled with 0.05% chlorine solution outside the door. Carefully place the dirty clothes or utensils into the bucket without leaving the room or touching the bucket. After 30 minutes, the bucket can be removed. The contents must be rinsed and washed with soap. Put clothes in the sun to dry. Wash the room If vomit or excreta are on the bed or on the floor, pour one cup of 0.5% chlorine solution over it. Leave it for at least 15 minutes and then mop up with the absorbent pad (green plastic side up). The mattress must be covered with the plastic sheeting provided. The sheeting can then be washed with an absorbent pad soaked with 0.5% chlorine solution. Disposal of faeces Pour 1 cm of 0.5% chlorine solution into the bucket. 220 After use pour another cup of 0.5% chlorine solution over the contents and put the lid on. Disinfect the outside of the bucket with 0.5% chlorine solution and place it outside the door. Leave the bucket for at least 15 minutes, and once undressed and outside the room again, put on clean gloves and pour the contents carefully into the latrine Disinfect the latrine once a day with 0.5% chlorine solution. Disposal of waste All waste has to be placed in a rubbish bag, When the bag is half-full, close the bag and disinfect the outside with 0.5% chlorine solution, place it outside the door. Once undressed and outside the room again, burn the bag in the burning pit. What the family should do if the patient dies Do not touch the body or any of the patient’s belongings. Close the door of the room. Inform the mobile team coordination. Wait for the decontamination and burial teams to arrive. 221 Annex 9.3 Information to Be Given To the Families What is Viral Hemorrhagic Fever (Marburg/ Ebola)? o It is a viral infection, and it can spread very quickly from one person to another. o It causes a rapid death in the majority of the cases. o Unfortunately, there is no known treatment. How Does a Person Become Infected with Marburg/Ebola? o Through direct contact with body fluids (blood, sweat, saliva, vomit, faeces, urine and semen of an infected person. o By touching a dead body of a Marburg / Ebola victim. o Through unsafe injections, blood tests, IV treatments and traditional medicines. What are the symptoms? o High fever. o Diarrhoea with or without blood. o Vomiting with or without blood. o Bleeding from the gums, nose or vagina, or any other unexplained bleeding. What can be done for a Marburg patient? o Rapid diagnosis and safe isolation. o Treating the symptoms that affect the patient helps to improve the general status of the patient so that he/she can fight the disease. o The family should accompany the patient to provide moral support. o Always use adequate protection so that the patient can be cared for safely without risk of contamination. o Safe burials including body disinfection, body bagging, and burial using coffin. o Ensure that the house is disinfected when the patient leaves. Evolution of an Infected Person? o A person can be infected through direct contact with body fluids of a symptomatic Marburg/ Ebola patient. o During the incubation period (3 to 21 days), the person feels normal, and cannot pass the disease to anybody else. o Symptoms start after the incubation period and include high fever, diarrhoea, vomiting, weakness, stomach ache, and loss of appetite, headache, body pains, and difficulty in swallowing. The person can pass the disease to other people once symptoms begin. o As the disease progresses the patient may develop haemorrhagic signs: bloody diarrhoea, bloody vomit, and bleeding from the gums, nose, or vagina. o If the patient’s condition worsens, he/she can develop confusion and convulsions, and bleeding can increase. Back to Table of Contents 222 Annex 10 Annex 10.1 Mental Health and Psychosocial Components Psychosocial Activities and Patient Flow VHF Patient Transfer to Hospital HBSRR Program House Disinfection Patient Deceased Patient Recovered House Disinfection Patient Deceased Patient Recovered Kit Distribution Burial Accompany Patient Home Kit Distribution Burial Accompany Patient Home Psychological follow up for patient, relatives, and/or community. Psychological follow up for patient, relatives, and/or community. Death in the House Burial House Disinfection Kit Distribution Psychological follow up for patient, relatives, and/or community Annex 10.2 Distribution of Solidarity Kit The Solidarity Kit is distributed to VHF patients upon their return home, or to their families in the event of their death. The contents of the kit are intended to replace those items that have probably been destroyed due to their admission in the VHF Treatment Ward, and during the house disinfection activities. Other objectives of distributing the kit include: Prevention and protection: direct access to recent contacts of the victims allowing early detection of potential VHF cases. Psychological care: provide essential care to victims of the epidemic. Community sensitisation: take advantage of the distribution to gain the confidence of the family and the community, and improve community sensitisation necessary for the control of the epidemic. Beneficiary Population The ultimate goal is to assist the entire population at high risk of contracting VHF. However, priority is given to the following: 223 Admitted or deceased VHF patients currently in the VHF ward of the hospital. Admitted or deceased VHF patients detected retrospectively. Medical staff of the hospital. Methodology Once the list of persons to be assisted has been decided upon, the following should be done: 1. Follow up of contacts immediately following discharge or death of the victim. 2. Delivery of the humanitarian kit to the family. 3. Evaluation of the family grieving process. 4. Psychological support in the grieving process if required. If the family agrees, psychological follow up can be done over a maximum period of three weeks, with the intention of evaluating possible psychological sequels due to the events that have occurred in the family. Measures of Success The family accepts the MSF team in their home. Information is provided by the family about possible warning signs in other family members. Atmosphere of confidence regarding feelings related to VHF. The transfer of other possible cases within the family to the treatment unit is facilitated. Contents of the Solidarity Kit Suggested contents of the components of the kit are given below; the contents and the numbers of items in the kit should be adapted to the context. Rest Kit 2 Mattress or mat 1 Mosquito net 2 Sheets 1 Blanket Personal Hygiene Kit 4 Towels 4 Soap 50 Condoms Cloths for menstrual use. Domestic Hygiene Kit Educational Kit 4 Bottles of bleach Pencils 2 Bars of washing-up soap Notebooks 5 Bars of laundry soap Eraser 4 Pairs of rubber gloves 1 Syringe (prep chlorine solutions) Clothing Kits – only for survivors of VHF Male Female 2 Pairs of trousers 4 Sarong dresses. 4 T-shirts 2 T-shirts 4 Pairs underpants 4 Pairs underpants 1 pair flip-flops 2 Brassieres Kitchen Kit (prepare sets of 4 and distribute according to the number of persons living in the house) 4 Glasses 4 Plates 4 Sets of cutlery (spoon, fork and knife) 4 Kitchen cloths 2 Scouring pads Medication Kit Analgesics for minor pain relief. Children & Babies 4 Trousers 4 T-shirts 8 Pairs underpants OR 8 Nappies 224 1 pair flip-flops 1 pair flip-flops Documentation Ensure that a Death Certificate signed by the doctor (should be a locally registered doctor for legal reasons) is provided in the event of death. Ensure that a Medical Discharge Certificate is provided in the event of recovery from VHF. o It is important that these are officially recognised documents for inheritance purposes, and possible future economic compensation by the National government. Positive VHF test results are only to be given directly to the victim, or to the guardian in the case of a minor. Explain that this is confidential information, and that they are under no obligation to tell anybody of their status. Provide information leaflets covering the following aspects: o If the patient has recovered from VHF, give convalescence health recommendations. o If the patient has died due to VHF, give preventative health guidance for the family of the victim. o General information about the disease including recognising symptoms and the actions to take if symptoms appear in a family member. Back to Table of Contents 225 Annex 11 Annex 11.1 Ambulance and Burial Services Checklist: Supplies for Ambulance Teams The following items must be carried in the vehicle. Verify the presence of all items listed in the following checklist before starting work. Item Spare Protective Equipment Plastic aprons Goggles Overalls Head covers Masks Examination gloves (box at least half full) Household gloves Other Equipment 10-litre spraying machine filled with 0.5% chlorine solution. 1-litre hand-sprayer filled with 0.05% chlorine solution Vinyl stretcher. Thermometer. Plastic rubbish bags. Hand soap. HTH granules and 1 measuring spoon Plastic cup. 10-litre jerry can filled with 10 litres of water for making additional 0.5% chlorine solution. Bucket with lid to hold re-useable protective items after use. *Yellow bucket with lid for emergency waste receptacle for patient en route. Absorbent pads Patient transport guideline. Guideline for preparing chlorine solutions. MSF Tape Quantity 2 4 pairs 4 4 4 1 box 2 pairs 1 1 1 1 4 2 bars 1kg 1 1 1 1 3 1 1 1 roll * Any waste disposed in the bucket must be disinfected immediately with 0.5% chlorine that can be poured from the 10-litre sprayer into the bucket. All of these items must be replaced immediately after use. The equipment must always be ready to use. 226 Annex 11.2 Checklist: Supplies for Burial Teams The following items must be carried in the vehicle. Verify the presence of all items listed in the following checklist before starting work. Item Spare Protective Equipment Plastic aprons Goggles Overalls Head covers Masks Examination gloves (box at least half full) Household gloves Other Items 10-litre spraying machine filled with 0.5% chlorine solution. 1-litre hand-sprayer filled with 0.05% chlorine solution. Vinyl stretcher. Rope cut to 5-meter lengths. Rope cut to 15-meter length. Plastic rubbish bags. Hand soap. HTH granules and 1 measuring spoon Plastic cup. 10-litre jerry can filled with 10 litres of water for making additional 0.5% chlorine solution. Bucket with lid to hold re-useable items after use. Plastic sheeting - 3m x 3m Burial guideline. Guideline for preparing chlorine solutions. Forms for recording details of burial, grave location etc. MSF tape Quantity 2 4 pairs 4 4 4 1 box 2 pairs 1 1 1 3 pieces 1 piece 4 2 bars 1kg 1 1 1 1 1 1 1 1 roll All of these items must be replaced immediately after use. The equipment must always be ready to use. 227 Annex 11.3 Guideline for Safe Burial Practices Burial Procedure for Patient Dying in the Treatment Unit Preparation of body Spray the body and the area around body with 0.5% chlorine. Spray sheet and/or blanket thoroughly with chlorine solution. Wrap body in blanket and cover completely. Open body bag and place body and personal clothing inside. Ensure face can be viewed when body bag is opened. Close body bag securely. Spray outside of body bag with 0.5% chlorine. Transport & burial Place body bag on stretcher. If relatives are present at the treatment unit, allow them to view and identify the deceased. If relatives are not present at the unit, wait until they arrive, or arrange to meet at the gravesite. Coffins used for burial: o Place body bag in coffin and close securely. o Spray the stretcher thoroughly. o Spray outside of coffin with 0.5% chlorine solution. o Burial team can then disinfect and remove High-Risk PPE. o Place coffin in vehicle and transport to gravesite. o Place ropes on ground at two or three intervals to use to lower coffin into grave, and place coffin on top of the ropes. o 4-6 persons lower coffin using the ropes into the grave. No coffins used: o Place stretcher and body bag in vehicle. o Transport to gravesite. o Place ropes on ground at two or 3 intervals (knee, lower back, upper back) to use to lower body into grave, and place body bag on top of the ropes. o 4-6 persons lower body using the ropes into the grave. o Spray the stretcher thoroughly with 0.5% chlorine solution. o Spray inside of vehicle with 0.5% chlorine and let stand for at least 15 minutes. Rinse vehicle with clean water upon return to the Treatment Unit o Spray gloves, apron, and boots with 0.5% chlorine solution. Undressing If coffins are used and they are of good quality, then once the body bag is sealed inside the coffin the burial team can undress and travel with the coffin normally. If no coffins are used, then the burial team must remain fully dressed while travelling with the body. Undressing is easiest done upon return to the treatment unit, where all the necessary facilities are installed. However, if this is not possible: Disinfect and remove protective clothing as per protocol. Discard disposable material (gown/overalls, head cover, mask, and surgical gloves) into plastic rubbish bag and close it, spray bag with 0.5% chlorine and put in second bag, close it. Spray again and transport to waste zone at treatment unit for disposal. Spray re-usable items: goggles, household gloves, and apron. 228 Place re-usable materials in bucket, spray again, and close lid. Disinfect hands with 0.05% chlorine solution. Rinse inside of vehicle thoroughly with clean water. Place stretcher in vehicle. Procedure for Burial of Suspect/Probable/Confirmed Patient Dying at Home Before giving protective materials, supervisor of burial team should enter the family compound to speak with responsible person in family. Explain burial procedure and provide information on VHF transmission. Explain why the body must be buried safely and explain the procedure for disinfection of the body. Ensure grave is prepared, 2 meters deep. Follow procedures as above for preparation of body and the use of body bag and/or coffin. After removing the body from the house, disinfect the room in which the patient died as well as the patient’s mattress. Burn the mattress. 229 Annex 11.4 Procedure to Clean VHF Ward after a Death Objective The isolation ward is made safe, disinfected, and cleaned, following the death of a patient. All activities are carried out in a safe way for staff, attendants, and other patients. Procedure 1. Following a death of a patient, the nurse in charge covers the body with a blanket. 2. The nurses put a screen around the bed of the deceased patient. 3. The burial team disinfect the body, put it in the body bag, and remove it from the ward. 4. Cleaners enter the room with full protective clothing. 5. Request other patients in the room/ward to leave the area if they are able to move. 6. Cleaners remove the mattress for burning in case of heavy contamination. a. Dirty mattress can be folded and tied with some strings or cloths. 7. All remaining clothes and blankets are put in a double plastic bag. 8. Mattress and bags with refuse are sprayed with 0.5% solution before transport. 9. Inform the waste burner that the material must be burned. 10. Cleaners collect all material used by the patient. 11. All plastic cups, cutlery, plates; buckets are washed with 0.05% solution. 12. The bed, window, walls, and the whole floor are disinfected with 0.5% chlorine solution by pouring with a cup or by spraying. 13. Put new mattress on the bed if necessary. 14. Remove screen from the bed. 15. Cleaners remove all cleaning material. 16. When leaving cleaners thoroughly disinfect aprons, boots, and gloved hands with 0.5% chlorine solution. 17. Inform the Nurse in Charge that the ward has been cleaned. 230 Annex 11.5 Example of Culturally Adapted Pre-Burial Body Washing In the funeral process, certain traditional practices are considered essential; however, these practices often introduce great risks of infection. In principle, the strict precautions linked to burial of VHF cases would prohibit many such practices. Nevertheless, safety precautions can be adapted so that some practices can be done in a way that is acceptable to the families, without compromising safety. One such practice is the washing and preparation of the body prior to burial: this can be done in a culturally acceptable manner, safely, and with respect. People Participating Family member: cultural factors may dictate whether a man or woman participates. They must be dressed in full protective clothing Two burial team members. A sprayer. A supervisor. Role of Each Person Family Member o Before starting, the family member is informed that he/she must follow all instructions given. o In principle, the family member should minimise contact with the body, and where acceptable, should only witness the process. If it is necessary to change the clothes of the deceased, the family member can assist. Burial Team Members o Assist with moving and lifting the body. o Assist with other activities as required. Sprayer o Does the initial spraying and disinfection of the body. o Stays on hand for further disinfection of the body, and disinfection of team’s hands, clothing, etc. o Does not take an active part in the preparation of the body. Supervisor o Helps the family member to dress and undress safely. o Washes and disinfects the body. o Ensures family member has safe contact with the body, and follows safety procedures. Procedure Dress up the family member and instruct him/her of their role. Do a preliminary disinfection of the body by spraying 0.5% chlorine solution. Remove clothes from the body. Disinfect hands and apron thoroughly with 0.5% solution. Use a cloth (absorbent pad) soaked with 0.5% chlorine solution to wash the lower part of the body. Start with the torso and then the legs. Use a fresh cloth for washing the face. Disinfect gloved hands and apron thoroughly with 0.5% solution. Dress the body again if required, if not roll in a piece of fabric. If acceptable, do another general spraying. Place body in body bag, close and spray thoroughly with 0.5% solution. 231 Annex 11.6 Procedure for House Disinfection House disinfection must be carried out in a sensitive manner. The process results in the destruction of some of the family’s belongings, and damage to other items may also occur. Clearly explain the procedure to the family, and obtain their agreement. Explain that a Solidarity Kit will be provided to replace the items destroyed. Objective Contaminated items and the area where the patient was accommodated are made safe and disinfected, following the death or transfer of a patient. All activities are carried out in a safe way. People Participating One family member: they must be dressed in full protective clothing Disinfection team: supervisor, sprayer, 2 waste handlers. Procedure 1. After the patient has left the room, the supervisor enters and assesses the area. 2. Disinfect by spraying 0.5% chlorine solution, the general area where the patient was accommodated. 3. Remove mattress, bedding, and clothing for burning in case of heavy contamination. 4. Dirty mattress can be folded and tied with some strings or cloths. 5. Material to be burnt should be bagged or wrapped in plastic sheeting and transported to the waste zone at the Treatment Unit for disposal. 6. Clothing that is not obviously contaminated can be disinfected and laundered. 7. Spray reusable hard items, such as plates, buckets, furniture, etc. with 0.5% solution, and clean. 8. Spray the bed, windows, walls, and the whole floor with 0.5% chlorine solution. 9. Spray the latrine with 0.5% solution. 10. Backfill any waste pits that have been used. Back to Table of Contents 232 Annex 12 Annex 12.1 Medical and Epidemiological Forms Triage Form Patient name: Date: Sex: m f Age: Register no.: Address/Location: Reason for consultation: Time & date illness started: Did they receive treatment before coming to the hospital? Yes No What kind of treatment? Where did they receive treatment? Hospital Health centre (name): Traditional healer: Other VHF Symptoms Fever Vomit Headache Diarrhoea Nausea Haemorrhagic eyes Other haemorrhage Breathlessness Bone/muscle pain Loss of appetite Asthenia/weakness Abdominal pain Jaundice Swallowing problems Hiccups Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No Patient Plan Medicine ward Orthopaedic ward Surgery ward Maternity ward Paediatric ward Remarks: Yes Temperature: Yes No Bloody Yes ºc. No Location Contact History Is there somebody ill in the family? Have you visited someone who is ill? Has somebody died recently in your family Have you been to a funeral recently? Suspicion of VHF # days: Bloody Yes Yes Yes Yes No No No No No Adult emergency Paediatric emergency VHF centre Health centre At home Name of nurse/doctor: 233 Annex 12.2 Medical Admission Form Most of the information in this form can be transferred to the Epidemiological Form Person filling form: ____________________________ Information provided by: ______________________ Case ID# _______________ MSF ID# _______________ Date: ___/___/______ Referral Case referred by: Epi team: Health Centre: Other: Family contact person: Identity of the Patient Name: __________________________ Surname(s): Age – years: ______ months: _______ Date of birth: ___/___/______ Sex: M: F: __________________________ Ethnicity/Language: ____________________ Residence: Head of family (name/surname): _______________________________ Community/District of residence: _______________________________ Address/Location: ___________________________________________ Profession: Farmer: Hunter: Housewife: Miner: Shopkeeper: Child/Student: Other: What: _______________________________ Health worker: Type: _______________________________ Institution/Location: ___________________ Details of the Illness When did the illness start? Date: ___/___/______ Have they had fever during the illness? Yes: # of days? →When did the fever start? Date: ___/___/______ ______ No: # of days? ______ Have they had vomiting during the illness? Yes: No: Have they had diarrhoea during the illness? Yes: No: Have they had bleeding during the illness? Yes: No: →When did bleeding start? Date: ___/___/______ # of days? ______ If there is a time difference between onset of symptoms, and seeking help, explain why? 234 Current Symptoms Yes: Temperature _______oC No: Headache Yes: how many days? _____ No: Bone or muscle pain Yes: how many days? _____ No: Stomach pain Yes: how many days? _____ No: Weakness Yes: how many days? _____ No: Anorexia Yes: how many days? _____ No: Swallowing problems or pain Yes: how many days? _____ No: Nausea Yes: how many days? _____ No: Vomiting Yes: how many days? _____ No: Diarrhoea Yes: how many days? _____ No: Breathlessness Yes: how many days? _____ No: Red or injected eyes Yes: how many days? _____ No: Non-haemorrhagic rash Yes: how many days? _____ No: Hiccups Yes: how many days? _____ No: Cutaneous bruising / Petechia Yes: how many days? _____ No: Cutaneous bleeding/injection sites Yes: how many days? _____ No: Bleeding gums Yes: how many days? _____ No: Diarrhoea with black or red blood Yes: how many days? _____ No: Haematemesis (bloody vomit) Yes: how many days? _____ No: Epistaxis (nose bleeds) Yes: how many days? _____ No: Vaginal Bleeding Yes: how many days? _____ No: Haemoptysis (coughing blood) Yes: how many days? _____ No: Fever on admission? Non-Bleeding Symptoms: Bleeding Symptoms: Other symptoms: Other findings: 235 Diagnosis Suspect Not Case Probable Confirmed If not a VHF case, what is the diagnosis? ________________________________________ Management/Admission VHF Treatment Ward Other hospital service HBSRR For Home Based Support and Risk Reduction: Name of caregiver: _________________ Location: _______________________ Laboratory Tests Date Sample Type Test Type Result Final Diagnosis Suspect Not Case Probable Confirmed If not a VHF case, what is the diagnosis? ________________________________________ Outcome Died Recovered Transferred Fled Comments: ___________________________________________________ 236 Annex 12.3 Observation Sheet Family name: First name: Identifier No.: Age: Day Date Temperature C Pulse Respiration Onset of symptoms: Date of admission: Date of discharge: Sex: Ad 2 3 4 5 6 7 8 9 10 11 12 13 14 Symptoms Headache Bone or muscle pain Stomach pain Tender abdomen Weakness/Fatigue Anorexia Swallowing problems Nausea Vomiting Diarrhoea Breathlessness Red or injected eyes Non-haemorrhagic rash Hiccups Oedema Anuria Haemorrhagic Symptoms Petechiae / Cutaneous bruising/ Bleeding injection sites Bleeding gums Bloody diarrhoea Haematemesis (bloody vomit) Epistaxis (nose bleeds) Vaginal bleeding Haemoptysis (coughing blood) Other Symptoms Psychological problems Notes Date: Date: Date: Date: Diagnosis: Prescribed treatment: 237 Annex 12.4 HBSRR Follow Up Sheet HBSRR Follow Up Sheet MSF nº Name: Sex: Name of Caregiver: First day of symptoms: Exit day : C: Day Date 1 Age: A: 2 3 D: 4 5 Location : T: 6 7 8 9 10 11 12 13 14 Vital Signs Temperature Pulse Respiratory Rate Symptoms Headache Bone/Muscle Pain Abdominal Pain Weakness Anorexia Swallowing pain/problems Nausea Vomiting Diarrhoea Breathlessness Red/Injected eyes Non-haemorrhagic rash Hiccups Haemorrhagic Signs Cutaneous bruising / Petechia Cutaneous bleeding/injection sites Bleeding gums Diarrhoea with black or red blood Haemetemesis (bloody vomit) Epistaxis (nose bleeds) Non menstrual - Vaginal Bleeding Haemoptysis (coughing blood) Other Signs Treatment / Notes 238 Watsan Follow Up Correct disposal of waste? Presence and use of clean safe water? Correct preparation of chlorine solutions? Correct cleaning of eating utensils? Correct cleaning and disinfection of apron and gloves? Correct cleaning of mattress and cover? Correct cleaning of patient’s clothing? Correct disposal of faeces, urine, and vomit? 239 Annex 12.5 VHF Treatment Sheet Name: ID No: MSF#: Record Time Medication Given Medication Dose 1 Artesunate Day 1 Hr: Day 2 06 2 Amodiaquine Hr: 06 3 Cotrimoxazole 3 ORS 06 16 Hr: 06 16 Hr: 4 Paracetamol 5 Cimetidine 6 Promethazine 7 Tramadol Day 11 Day 12 Day 13 Day 14 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 06 16 Hr: 06 16 Hr: 06 16 Hr: Hr: Hr: Hr: Hr: Hr: Hr: Hr: Hr: Hr: Hr: Hr: Hr: Hr: Hr: Hr: 06 16 16 16 06 16 Hr: 06 16 Hr: Hr: Day 10 Day 3 Hr: Hr: Hr: Hr: Hr: 8 9 10 11 12 240 Annex 12.6 Contact Tracing Form Contact Tracing Form Team Name of patient Sex Name of contact Address / Location Village Leader Community / District Type of contact 1. Slept in same house 2. Direct physical contact Date of last contact ___ / ___ / ___ M F Age 3. Touched body fluids 5. Breastfeeding 4. Manimpulation of clothes or other objects Day of follow-up 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Fever Vomiting or nausea Diarrhoea Weakness Any haemorrhagic sign Comments 241 Annex 12.7 Contact Recording Form Patient Name: Age: Sex: Address/Location: First name of contact Community/district of residence: Village Leader: Surname/family name of contact Relationship to case *Types of Contact: 1 = Slept in same house in last 21 days 2 = Direct physical contact Age (yrs) Sex (m/f) Name of head of household 3 = Touched body fluids 4 = Sexual relations Date: Address/Location Contact Type* (1, 2, 3, etc) Date of last contact 5 = Handled clothes/personal objects 6 = Breast feeding 242 Annex 12.8 Epidemiological Form Person filling form: ____________________________ Information provided by: ______________________ Case ID# _______________ MSF ID# _______________ Date: ___/___/______ Referral This can be transferred from the Medical Admission Form Case referred by: Epi team: Health Centre: Other: Family contact person: Identity of the Patient This can be transferred from the Medical Admission Form Name: __________________________ Surname(s): Age – years: ______ months: _______ Date of birth: ___/___/______ Sex: M: F: __________________________ Ethnicity/Language: ____________________ Residence: Head of family (name/surname): _______________________________ Community/District of residence: _______________________________ ___________________________________________ Address/Location: Profession: Farmer: Hunter: Housewife: Miner: Shopkeeper: Child/Student: Other: What: _______________________________ Health worker: Type: _______________________________ Institution/Location: ___________________ Contact with VHF Patients Has the patient had contact with someone with VHF or someone who has been ill recently? Name of VHF patient Relationship Date of contact Symptoms Type of contact* *In case of contact with someone with VHF (or probable VHF), what was the closest contact: 1 - Slept in same house within the last 21 days. 2 - Had direct physical contact. 3 - Touched their body fluids (excreta, vomit etc.) 4 - Had sexual relations. 5 - Handled clothes or other personal objects. 6 - Suckled patient or breast-fed from patient. 243 Funerals Has the patient been to a funeral in the last 21 days? Yes: No: Did they touch or manipulate the body? Yes: No: Name of deceased: ______________________ Date of funeral: ___/___/______ Medical Treatment Received in the last 21 days Has patient received medical treatment in the last 21 days? Date(s) that this treatment was received: What treatment was received: Yes: Injection Hospital Traditional Healer Other No: ___/___/______ Tablets Other (herbs, cuts, enemas, etc.) Where was treatment received: Private Clinic Location: Contact with Dead or Sick Animals Has patient had any physical contact with a dead or sick animal in the last 21 days? Yes: No: What kind of contact did the person have: What kind of animal? Details of the Illness When did the illness start? This can be transferred from the Medical Admission Form Date: ___/___/______ Have they had fever during the illness? Yes: # of days? →When did the fever start? Date: ___/___/______ ______ No: # of days? ______ Have they had vomiting during the illness? Yes: No: Have they had diarrhoea during the illness? Yes: No: Have they had bleeding during the illness? Yes: No: →When did bleeding start? Date: ___/___/______ # of days? ______ If there is a time difference between onset of symptoms, and seeking help, explain why? 244 Current Symptoms This can be transferred from the Medical Admission Form Yes: Temperature _______oC No: Headache Yes: how many days? _____ No: Bone or muscle pain Yes: how many days? _____ No: Stomach pain Yes: how many days? _____ No: Weakness Yes: how many days? _____ No: Anorexia Yes: how many days? _____ No: Swallowing problems or pain Yes: how many days? _____ No: Nausea Yes: how many days? _____ No: Vomiting Yes: how many days? _____ No: Diarrhoea Yes: how many days? _____ No: Breathlessness Yes: how many days? _____ No: Red or injected eyes Yes: how many days? _____ No: Non-haemorrhagic rash Yes: how many days? _____ No: Hiccups Yes: how many days? _____ No: Cutaneous bruising / Petechia Yes: how many days? _____ No: Cutaneous bleeding/injection sites Yes: how many days? _____ No: Bleeding gums Yes: how many days? _____ No: Diarrhoea with black or red blood Yes: how many days? _____ No: Haematemesis (bloody vomit) Yes: how many days? _____ No: Epistaxis (nose bleeds) Yes: how many days? _____ No: Vaginal Bleeding Yes: how many days? _____ No: Haemoptysis (coughing blood) Yes: how many days? _____ No: Fever on admission? Non-Bleeding Symptoms: Bleeding Symptoms: Other symptoms: Other relevant medical history: Other findings: Diagnosis This can be transferred from the Medical Admission Form 245 Suspect Not Case Probable Confirmed If not a VHF case, what is the diagnosis? ________________________________________ Management/Admission This can be transferred from the Medical Admission Form VHF Treatment Ward Other hospital service HBSRR For Home Based Support and Risk Reduction: Name of caregiver: _________________ Laboratory Tests Date Location: _______________________ This can be transferred from the Medical Admission Form Sample Type Final Diagnosis Suspect Not Case Test Type Result This can be transferred from the Medical Admission Form Probable Confirmed If not a VHF case, what is the diagnosis? ________________________________________ Outcome Died This can be transferred from the Medical Admission Form Recovered Transferred Fled Comments: ___________________________________________________ Burial Who conducted the burial? Family Other Mobile team MSF Who? ____________________________________________ Back to Table of Contents 246 Annex 13 Information for Patients, Discharged Patients, & Relatives To complement the briefings and explanations that must be done for all admissions and their relatives, information sheets translated into the appropriate languages can be provided. If they are unable to read, the sheets should still be provided with the contents explained verbally. Information sheets using pictograms illustrating the most important aspects can also be prepared. The information can also be presented as posters in, and at the entrance to the treatment unit. Information For New Admissions To The VHF Treatment Unit Welcome. You have been admitted to the VHF Treatment Unit. This means that a doctor has examined you and thinks you may have Ebola/Marburg disease. It is important to stop Ebola/Marburg from spreading to other people including friends, family or health staff. Some ways to do this are: Avoid unnecessary contact with other people. o Only one visitor per day for one hour. Staff and visitors will wear protective clothing. o Mask, gloves, goggles, apron, and boots. No personal items are allowed to leave the unit. o Do not pass items over the fence, e.g. plates, pots, blankets, etc. Do not touch or close to unprotected people. o Stay at least 1 metre from the fence if talking to someone. Remain in the unit until your treatment is finished. o You will be discharged when the doctor decides that you cannot infect other people. You will receive a kit of material upon arrival. This is for your use and should not be shared or given to other people. The kit includes a plate, cup, sheets, drinking bottles, plastic bags, absorbent pads, soap, and a thermometer with holder. Whilst in the unit, you should try to drink as much water and fluids as you can, eat healthily and walk around inside the unit when possible. If you have any questions, or concerns please discuss them with the staff. Leaving the VHF Treatment Unit The doctor has examined you, and it is now safe for you to go home or to be transferred to the main hospital. This means that you will not infect other people with Ebola/Marburg. Before leaving the unit: The cleaning team will clean and disinfect all your personal items. Blankets CANNOT be taken from the unit. We will provide you with new items if you brought your own. You will need to arrange for a fresh set of clothes to be brought to the unit for you to wear when you leave. Your other clothes will be cleaned and may be collected the following day. 247 Take all medication as prescribed by the doctor. When You Are at Home After recovery, you may still feel weak for 1 to 2 months. It is important to: Take plenty of rest. Eat a mixture of foods e.g. bread, vegetables, fruit, meat, beans. Take the multivitamin tablets provided for one month. Drink as much water as you can If you get sick, especially if you have fever, you should go to a health facility for examination and treatment. Note: If you are male there is a possibility of transmitting Ebola/Marburg during sexual intercourse, you should abstain, or use condoms for 3 months after discharge. Advice to Relatives Your friend or relative has just been admitted to the VHF Treatment Unit. This is to help them receive treatment, to prevent you from becoming sick, and to avoid infecting other people as well. We ask for your assistance and cooperation in observing the following regulations to help us to fight this disease. Only one relative may enter the unit, ? times per day, for ? hour(s). When visiting the use of the protective material will be explained, and you must wear the material that is supplied to you. Do not touch the patient. Do not touch infectious material e.g. vomit, diarrhoea, beds, cups or spoons. In the event of someone passing away, do not touch the dead body: inform the staff who will take care of the situation. Do not eat or drink anything inside the unit. When leaving the Unit, the method to remove of the protective material will be explained, and you must remove all of the protective material. Always wash your hands and spray your feet when leaving the unit and when asked to do so. Adapt as required. Back to Table of Contents 248 Annex 14 Annex 14.1 Staff Training – VHF Treatment Unit and Health Centres Example of Training Module for VHF Treatment Unit Personnel Introduction This module is designed for medical personnel but can be modified for training cleaners, guards, and other workers in the unit as required. It should be revised in accordance with new information as it becomes available. 1. History a. Previous outbreaks of Ebola and Marburg associated with human disease 2. Epidemiology a. Geography. b. Reservoir. c. Demography: age, sex d. High risk: pregnant women, HIV positive, infants (especially malnourished), health care workers, care givers. 3. Virology a. Human Ebola strains: Ebola Sudan, Ebola Zaire (also infects primates) b. Monkey Ebola strains: Ebola Reston, Ebola Ivory Coast (humans infected by contact with sick monkey. c. Marburg: both humans and monkeys can be infected 4. Pathophysiology a. Sites most affected by viral infection b. Physiologic consequences 5. Clinical Course of Ebola VHF a. Ebola incubation period: 2-21 days but usually 7-14 days before symptoms begin. A person in the incubation period cannot transmit Ebola infection. b. Marburg incubation period: 3-9 days but usually 4-5 days before symptoms appear. A person in the incubation period cannot transmit Marburg infection. c. Onset of infectivity and possibility of transmission begins with onset of symptoms. d. Early symptoms: Day 1-2 i. Systemic abrupt fever, headache, joint and muscle pain, asthenia, and anorexia gastrointestinal: nausea, vomiting, watery diarrhoea, and abdominal pain. e. Mid course: Day 3-6 i. Epigastric and RUQ pain (hepatic area), hepatomegaly ii. Bloody diarrhoea, melena iii. Dehydration, hypokalaemia iv. Conjunctival injection v. Basilar rales, cough vi. Substernal burning chest pain vii. Progressive weakness viii. Sore throat f. Late signs: Day 5-7 i. Fine maculopapular rash, sparing face ii. Bleeding signs: epitasis, haematemesis, subconjunctival haemorrhage, oozing from venipuncture sites, gingival haemorrhage, and melena. iii. Circulatory failure. iv. Anuria, ascites, oedema. 249 v. Tachypnoea, pulmonary oedema occasionally (?iatrogenic) vi. Confusion, disorientation, agitation, coma. g. Time to death: 10-12 days from onset of symptoms, often less (median Gulu 8 days) h. Time to recovery: 12-17 days from onset of symptoms: usually begins by day 8 i. Sequelae: myalgia, arthralgia, visual loss, uveitis, conjunctivitis, suppurative parotitis, unilateral orchitis, tinnitus, hearing loss, bizarre behaviour ultimately resolving (Sudan) 6. Prognosis a. Sex: no difference in mortality. Limited data HIV: 7/8 died b. Age: worse with increased age: (Kikwit: 95% over age 59 died) c. Pregnancy: note frequency of abortions: 95% mortality of pregnant women 7. Transmission a. Unprotected contact with body fluids including urine, blood, stool, breast milk, and sweat, close body contact (sleeping in same bed), contact with clothing of patient. b. Contact with corpse through washing or touching body (late stage disease and corpse have high levels of virus and are most infectious) c. Asymptomatic persons including contacts cannot transmit infection d. Not airborne but transmitted by droplets (coughing, spitting, projectile vomiting) e. Semen from convalescent case may transmit infection for up to 3 months f. Contact with sick primate (Reston, Ivory Coast) or carcass of dead primate (Gabon) 8. Case Definition: according to case definition being used. 9. Diagnosis And Antibody Response a. Clinical: fever and history of contact with known cases are most useful tools b. PCR: may be positive as early as 1-2 days after onset but false positives are a risk c. ANTIGEN: usually positive by day 4 of illness d. IgM: early antibody: appears between day 2 – 9 of clinical illness, usually gone by 6 weeks e. IgG: appears day 6 – 18 of illness and may last 2 years (or more). Thought to protect against subsequent infection with same strain. Cross protection against Ebola Sudan by antibody to Ebola Zaire but not vice versa. 10. Laboratory Data a. Liver tests: AST sensitive early indicator (day 1 or 2 of illness). LDH also high. Modest elevation of alkaline phosphatase and ALT, normal bilirubin. b. Haematology: decreased lymphs, increased granulocytes, decreased platelets mild DIC parameters in single case reports. c. Miscellaneous: i. Increased amylase, unknown source. ii. Increased creatinine, BUN. iii. Hypokalaemia related to G.I. losses. iv. Hypoxemia: terminal with O2 saturation in the 80’s, multifactorial. v. Skin biopsy: post mortem: + in nearly 100% Ebola Zaire, about 70% of Ebola Sudan. 11. Treatment a. Symptomatic: hydration, nutritional support, pain medication, selective antimalarial and antibiotic treatment depending on clinical evaluation. b. Avoid injections and infusions as far as possible. 12. Standard And VHF Precautions: see Annex 5.3 Standard Precautions, and Annex 5.4 Additional Precautions to Reduce VHF Transmission in Health Structures. 250 13. Protocols for Putting on And Removing Protective Clothing: see Annex 5.2 Dressing & Undressing Protocols. 14. Preparation of Chlorine Solutions: see Annex 5.10 Preparation of Chlorine Solutions. 15. Training In VHF Treatment Unit (model or actual unit): a. Review rationale, organisation, and plan. b. Principles of separation of suspect and confirmed cases. c. High-risk and low-risk areas. d. Job descriptions. Annex 14.2 Example of Training Module for Health Centres 1. Viral Haemorrhagic Fevers: (see general lecture for VHF Treatment Unit Staff: Annex 14.1 Example of Training Module for VHF Treatment Unit Personnel a. History of previous outbreaks. b. Viral strains associated with outbreaks. c. Reservoir. d. Incubation period. e. Signs and symptoms. f. Transmission and notion of contact: how disease is spread and NOT spread, persons most at risk. g. Diagnosis: see Annex 1.2 Diagnosing Filoviruses 2. Management of Suspected VHF Case in Health Centre a. Report suspect case immediately and request ambulance via established communication channel. b. Place patient in identified isolation (holding) area on mattress covered with plastic sheeting. c. Provide bucket with fresh 0.5% chlorine solution in bottom for collection of body waste and vomit. d. Provide cup for water. e. Avoid touching or treating patient: if unavoidable put on disposable gloves, plastic apron. f. Instruct patient attendant to avoid direct contact with patient, clothing, or body fluids. If possible, provide disposable gloves to attendant. g. Prepare small pit for disposal of decontaminated waste, clothing, gloves, or other materials used during patient’s stay in centre. h. Disinfect mattress cover, utensils used by patient with 0.5% chlorine solution. 3. Management Of Suspected VHF Case In Community a. Isolate patient from other family members. b. Instruct family not to touch patient if possible and to wash hands with soap after any contact with patient, body fluids, clothing, or bedding. c. Instruct family that patient should use separate latrine facility if possible. d. Report case immediately and request ambulance via established communication channel. 4. Standard Precautions a. Misdiagnosis of VHF is possible, and standard/universal precautions are the most effective way to avoid inadvertent infection of health workers and other patients. 251 b. Exposure during delivery or abortion poses risks that require protective measures. c. Standard precautions with VHF modifications i. Personal protection: hand washing, use of protective materials. ii. Cleaning and disinfection of beds, examination tables, etc. between patients. iii. Cleaning and sterilisation of instruments. iv. Cleaning of re-usable protective materials: aprons, boots, and household gloves. v. Cleaning of floors, latrines with soap and water. 5. Disinfection a. Preparation of chlorine solutions using locally available chlorine products (assuming that the concentration of chlorine is known). b. Use of “strong” (0.5%) and “dilute” (0.05%) solutions 6. Community Education a. Instruct community on modes of VHF transmission, and emphasise the reason and need for prompt isolation and referral to proper treatment facility. b. Instruct community on how to manage patients at home until transport arrives. Back to Table of Contents 252 Annex 15 ! Job Profiles and Task Descriptions The following job profiles and task descriptions are examples similar to those used in previous interventions. They must be adapted to the context, and the number and type of staff employed, etc. Annex 15.1 Data Collector for Mortality Surveillance Objective of the Post: To ensure reliable mortality surveillance during the epidemic. Overall mortality is an important indicator and an integral component of the overall disease surveillance system. Responsibilities: Data Collector is aware of the risks involved in carrying out his/her duties. Data Collector follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. 6 days per week (Monday to Saturday included), go to the districts where the most important cemeteries are located (list given below). Ensure daily collection of the number of new graves from the previous day, and only from the previous day. For each cemetery, first contact the manager of the cemetery to obtain his/her data from the previous day. In case this person is absent, or in case there is no such responsible, the Data Collector should contact the local leader of the area. After this contact, the Data Collector goes to the cemetery to see the new graves. The Data Collector must verify whether the information given is correct. Once all information is verified, the Data Collector notes down – per cemetery – the number of new graves, separating children and adults, from the previous day. For each new grave, as many details as possible should be noted (name, age, sex, by whom the burial was done, etc.). In case of doubts or uncertainties, record the details and discuss with the MSF supervisor. After visiting each cemetery, return to the MSF office in order to transmit the data to the supervisor. Cemeteries to Be Visited: List …… In case of changes in the situation, one or more cemeteries can be included, or excluded. Accountable to: Supervising Epidemiologist Working hours: 0900 – 1800 (adjust for operating hours of cemeteries). 253 Annex 15.2 Data Collector for the Treatment Unit Objective of the post: To ensure reliable recording of all necessary epidemiological information for patients admitted in the treatment unit. Responsibilities: Data Collector is aware of the risks involved in working in the treatment unit. Data Collector follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. Regularly update the data according to the new admissions of the day (2 or 3 times per day): o Fill in the form for each new admission. o Note the patient characteristics (age, sex, origin). o Follow-up of the lab results of all the samples taken. o Follow-up of the final diagnosis of the patients in coordination with the medical doctor. o Record the outcome for each patient: discharged, died, runaway, transferred. Collect and follow-up the complete information of the case report form: o Patient number and identity. o Full questionnaire. o History of patient exposure. o Clinical examination. Update the data on the daily admissions and exits in the treatment unit: o Between 17h of the previous day, up to 17h of the current day. Verify and complete the information on the contacts of each patient: o Ensure precise information allowing the identification and locating of the contacts for contact tracing purposes. To pass all information every day to the supervisor. Accountable to: The Data Collector for The Treatment Unit is accountable to the Supervising Epidemiologist. Working hours: 0900 - 1800 254 Annex 15.3 Doctor in Charge of the VHF Treatment Unit Objective of the post: The Doctor in Charge is responsible for managing the unit, and overseeing all medical related activities. S/he must follow up on activities and procedures in the wards, including admission and discharge of patients, the evolution of the patients, staff issues, and any problems that may arise. S/he is also responsible for supervising the doctors and clinical officers. S/he is responsible to ensure that the unit is accepted and integrated within the health structure, and to ensure that other health staff are informed and understand the measures put in place and the procedures for referring patients to the unit. Responsibilities: Doctor is aware of the risks involved in working in the VHF treatment unit. Doctor follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. Management of the treatment unit. Coordination with Head Nurse. Ensures that all new staff members are trained properly. Organises and chairs a weekly meeting with the medical and non-medical staff working in the treatment unit. Responsible for forwarding relevant problems and issues arising from the weekly meeting to the medical superintendent/hospital authorities. Prepares duty roster for doctors and clinical officers. Visits the treatment wards or communicates with the Doctor on Duty at least twice a day. Records data and patient information as required. Informs Medical Superintendent and coordination team of the situation in the treatment unit. Accountable to: The Doctor in Charge of the VHF Treatment Unit is accountable to the Medical Superintendent of the hospital. Working hours: On call 24 hours per day. 255 Annex 15.4 Doctor on Duty in the VHF Treatment Unit Objective of the post: The Doctor and Clinical Officers are responsible for the clinical care and the evolution of the patients. They must be present when a new patient arrives and ensure that the appropriate protocols are respected. Responsibilities: Doctor is aware of the risks involved in working in the VHF Treatment unit. Doctor follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. Performs a ward round twice a day. Attends to patients according to the clinical evolution. Prescribes treatment in the patient file. Verifies that the treatment has been given according to the prescription. Informs the doctor in charge of the VHF Treatment unit about the evolution of the patients admitted. Attends to new admissions as soon they arrive: o Fills in the patient form. o Informs the laboratory technician responsible for blood sampling. Coordinates with the Head Nurse and nursing staff, ensuring the follow up of infection control and protective measures. Participates in the weekly meeting of the VHF Treatment unit. Accountable to: The doctor is accountable to the Doctor in Charge of the VHF Treatment Unit. Working hours: On call 24 hours a day. Working hours according to shift requirements. 256 Annex 15.5 Head Nurse of the VHF Treatment Unit Objective of the post: The head nurse coordinates and manages the nursing staff. S/he ensures that proper care is provided to the patients and that the care corresponds to the doctor’s orders. S/he also ensures that all activities in the wards are carried out safely. Responsibilities: Head Nurse is aware of the risks involved in working in the VHF Treatment unit. Head Nurse follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. Coordinates with Doctor in charge. Supervises nursing staff. Prepares duty roster for the nurses. Ensures that sufficient protective equipment and materials are available in the dressing rooms. Orders protective equipment and materials when required. Ensures that the protective gear is used properly, and that safety protocols and infection control measures are followed. Monitors the consumption of drugs, and orders as necessary. Organises orders of other requirements Organises staff handovers between each shift. Supervises training of new nurses, and closely monitors and supervises their activities until able to work independently Accountable to: The Head Nurse is accountable to the Doctor in Charge of the VHF Treatment Unit. Working hours: Working hours according to shift requirements. Otherwise on call during daytime. 257 Annex 15.6 Water, Sanitation and Hygiene Coordinator Objective of the post: Ensures that the management of the water, sanitation, hygiene, and waste activities are organised so that staff, patients, and the environment inside and outside the VHF Treatment Unit are not exposed to VHF contaminated material. Responsibilities: The coordinator is aware of the risks involved in working in the VHF Treatment Unit. The coordinator follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. General responsibilities: o Responsible for all water, hygiene and sanitation issues linked to the outbreak intervention. o Trains and educates staff of the hospital and other health structures in the affected area with respect to VHF and watsan related issues. o Takes every opportunity to inform and sensitise the population when working in the field. o Attends and participates actively in weekly staff meeting. o Attends and participates actively in the Task Force meetings. o Advises the hospital authorities on general health care waste issues. o Monitors and orders stocks of cleaning and disinfection material. o Coordinates with Head Nurse for the monitoring and ordering of PPE, and other materials. Human Resource Management: o Provides technical support to other watsan staff (local & expatriate). o Supervises and guides the VHF ward support staff. o Supervises and guides the mobile teams. o Prepares and adapts job descriptions according to the needs. Water, Hygiene and Sanitation o Ensures that safety procedures are implemented in all outbreak control activities. o Ensures that sufficient good quality water is available in the VHF Treatment Ward. o Ensures that sufficient quantities of chlorine solution are always available. o Ensures that latrines and bathing areas are well maintained, and cleaned and disinfected properly. o Ensures that staff and patients are following the protection regulations o Ensures that waste is collected, handled, transported, and disposed of safely and according to the protocols. Accountable to: The Water, Sanitation, and Hygiene Coordinator is accountable to the Medical Coordinator in the capital, project coordinator in field. Working hours: Working hours according to shift requirements. 258 Annex 15.7 Nurse – VHF Treatment Unit Objective of the post: The nurse provides care to the patients, attends to their needs, and ensures they are comfortable. S/he records and communicates information regarding the evolution of the patients. Responsibilities: Nurse is aware of the risks involved in working in the VHF Treatment Unit. Nurse follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. Takes the vital signs at least once per shift and records in the patient file. Gives treatment at the appropriate time as prescribed by the doctor. Calls the doctor on duty if any medical problem arises. Ensures that each patient always has ORS or plain water for rehydration. Assists patients in taking fluid as required or as prescribed by the doctor. Ensures that the patients are comfortable. Ensures that the patients and their bedding are clean. Assists the patients with bathing and personal hygiene. Informs the supervisor of the burial team when a patient dies. Assists with the doctor’s ward rounds, and records the necessary medical information. Makes a detailed report at the end of the shift in the report book. Records new patients in the admission book, and completes other data forms as required. Attends and participates in the weekly meeting. Informs the surveillance team of the general condition of the patients (to inform the relatives at home). Ensures that the items for admission are in place before each admission. Explains the rules of the VHF Treatment Unit to all new patients, and their relatives. Provides the necessary protective gear to the relative and ensures that they are familiar with the rules of the VHF Treatment unit. Accountable to: The nurse is accountable to the Head Nurse of the VHF Treatment Unit. Working hours: Working hours according to shift requirements. 259 Annex 15.8 Watsan – VHF Outbreak Control Objective of the post: Ensures that water, sanitation, hygiene, and waste activities are carried out so that staff, patients, and the environment inside and outside the VHF Treatment Unit are not exposed to VHF contaminated material. Responsibilities: The watsan is aware of the risks involved in working in the VHF Treatment Unit. The watsan follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. General responsibilities: o Follows up water, hygiene, and sanitation issues linked to the outbreak intervention. o In collaboration with the coordinator, trains and educates staff of the hospital and other health structures in the affected area with respect to VHF and watsan related issues. o Takes every opportunity to inform and sensitise the population when working in the field. o Attends and participates actively in weekly staff meeting. o Monitors stocks of cleaning and disinfection material. o Coordinates with Head Nurse for the monitoring and ordering of PPE, and other materials. o Reports activities to the coordinator. Human Resource Management: o Provides technical support and supervises VHF ward support staff. o Supervises and guides the mobile teams in the field. Water, Hygiene and Sanitation o Ensures that safety procedures are implemented in all outbreak control activities. o Ensures that sufficient good quality water is available in the VHF Treatment Ward. o Ensures that sufficient quantities of chlorine solution are always available. o Ensures that latrines and bathing areas are well maintained, and cleaned and disinfected properly. o Ensures that staff and patients are following the protection regulations o Ensures that waste is collected, handled, transported, and disposed of safely and according to the protocols. Accountable to: The Watsan – VHF Outbreak Control is accountable to the Medical Coordinator in the capital, and the Water, Sanitation, and Hygiene Coordinator in the field. Working hours: Working hours according to shift requirements. 260 Annex 15.9 Laundry Person / Chlorine Solution Maker – Low-risk Zone Objective of the post: Sufficient chlorine solution in the appropriate strength is prepared and available in all parts of the VHF Treatment unit. Laundry is collected, disinfected, washed, dried, and returned. Responsibilities: The worker is aware of the risks involved in working in the VHF Treatment Unit. The worker follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. Prepares 0.5% and 0.05% chlorine solutions, and ensures all containers in the low-risk zone are filled with the appropriate fresh solution on a daily basis. Ensures that all containers in the low-risk zone are replenished with the appropriate chlorine solution throughout the day. Fills sprayer machines as required. Empties all footbaths and refills with 0.5% solution at least twice per day. Keeps stock of all necessary material and orders in time from the head nurse Collects dirty laundry (scrub suits) from changing room. o Disinfect in 0.05% chlorine solution for 30 minutes and rinse with water o Wash with detergent and rinse with water. o Hang on drying line. Folds dried items and returns to the appropriate places. Accountable to: Chlorine maker is accountable to the Water, Sanitation, and Hygiene Coordinator. Working hours: According to shift requirements. Working hours are from 8 am until 5 pm. 261 Annex 15.10 Waste Collector/Burner Objective of the post: All waste is collected, transported and burnt or disposed of in the appropriate place. All tasks are carried out in a way that is safe for him/her, for the other staff, the patients and the environment. Responsibilities: The worker is aware of the risks involved in working in the VHF Treatment Unit. The worker follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. The Waste Collector wears full protective clothing: boots, double pair of gloves, overall/gown, apron, head cover, mask, and goggles. Collects rubbish bags when ¾ full and transports to waste zone. Rubbish bags must be closed, and the outside of the bag sprayed before removing to the waste zone. Bags of burnable waste are placed in the drum burner and burnt. Organic waste is disposed in the organic waste pit. Assists cleaners when necessary or requested Accountable to: The Waste Collector is accountable to the Water, Sanitation, and Hygiene Coordinator. Working hours: According to shift requirements. Working hours are from 8 am until 5 pm. 262 Annex 15.11 Cleaner – High-Risk Zone Objective of the post: The suspect case area and the probable/confirmed case area are kept clean and tidy. All tasks are carried out in a manner that is safe for him/her, for the other staff, the patients and the environment. Responsibilities: The worker is aware of the risks involved in working in the VHF Treatment Unit. The worker follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. Prepares sufficient stock of 0.5% and 0.05% solutions for use inside the high-risk area. Disinfects and cleans the floors with 0.5% solution in the morning and in the afternoon. Disinfects and cleans the latrines and bathrooms with 0.5% solution at least two times a day. Disinfects the beds as required with 0.5% chlorine solution and rinses with clean water (move the patient from bed). Disinfects and cleans patients’ plates, cups, and cutlery and ensures all patients receive back their own material. After patients are discharged, disinfects all personalised buckets, cups, bed, etc. Liquid waste (vomit, blood or stools in a bucket): o Ensures all the yellow buckets contain one cup of 0.5% solution. o Fill bucket containing vomit or stools with 0.5% solution (so that waste is completely covered) and soak for 15 minutes. o Dispose of the treated waste into the latrine pit. o Wash the bucket and the latrine with 0.5% solution. Spilled stools, vomit or blood on ground, bed or blanket: o Pour 0.5% solution directly on the spot and leave to soak for 15 minutes. o Clean the area with absorbent pad. Assists nursing staff with washing the patients. Assists nursing staff with feeding the patients. Accountable to: The cleaner is accountable to the Water, Sanitation, and Hygiene Coordinator. Working hours: Working hours according to shift requirements. 263 Annex 15.12 Guard – Changing Room 1 Objective of the post: All people entering the VHF Treatment Unit are screened, and unauthorised persons are not permitted to enter. All people exiting the VHF Treatment Unit have their hands and feet disinfected before leaving. Responsibilities: The worker is aware of the risks involved in working in the VHF Treatment Unit. The worker follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. The guard wears a scrub suit, boots, and gloves. The guard screens all people at the entrance and only allows authorized people to enter. Informs the nurse on duty about any visitors. Ensures that all people put on the appropriate protective material for the low-risk area. Ensures that all people exiting the area have their hands and soles of their shoes disinfected before leaving. Ensures that no material belonging to the VHF Treatment Unit leaves the area. Accountable to: The Guard is accountable to the Head Nurse of the VHF Treatment unit. Working hours: Working hours according to shift requirements. 264 Annex 15.13 Psychological & Psychosocial Coordinator Objective of the post: Coordinates and manages psychological staff, and ensures that all patients and families are offered appropriate psychological support. Responsibilities: The Coordinator is aware of the risks involved in working in the VHF Treatment Unit. The Coordinator follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. General Responsibilities o Responsible for all psychological and psychosocial activities linked to the outbreak intervention. o Analyses and plans activities of the mental health team. o Takes every opportunity to inform and sensitise the population when working in the field. o Participates in interagency meetings dealing with psychological issues, and social mobilisation as required. o Attends and participates actively in weekly staff meeting. Human resource Management o Supervises and guides the mental health team: Inpatient Psychologist, Community Psychologist. o Provides technical support to the mental health team as required. o Prepares and adapts job descriptions according to the needs. o Identifies, recruits, and trains staff as required. Psychological and Psychosocial Activities o Ensures that patients are able to benefit from the psychological assistance available. o Assesses capacity of staff and conducts training sessions as required. o Organises and leads regular meetings and debriefings for the mental health team. o Provides support to other outbreak team members as required. Accountable to: The Psychological & Psychosocial Coordinator is accountable to the Medical Coordinator in the capital, Project Coordinator in field. Working hours: Working hours according to shift requirements. 265 Annex 15.14 Psychologist for Inpatient Activities Objective of the post: Provides psychological care to patients admitted to the VHF Treatment Unit. Responsibilities: The Psychologist is aware of the risks involved in working in the VHF Treatment Unit. The Psychologist follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. General Responsibilities o Takes every opportunity to inform and sensitise patients, relatives, staff members and the population. o Informs the coordinator regarding any staff member in the event of psychological difficulties. o Provides technical support to the mental health team as required. o Participates in medical coordination meetings. o Participates in mental health team meetings, and brief daily meetings with the medical team to update on the evolution of each patient. o Attends and participates actively in weekly staff meeting. Psychological and Psychosocial Activities o Receives new cases in the treatment ward: initially for psychological intervention with the patient, and after admission provides support to the family. o Provides regular psychological follow up of the patient and family. o Ensures psychological concerns and interventions are recorded in the individual patient files. o Accompaniment of families in the event of the patient dying in hospital. Collaborates with the family in preparation for the funeral. If time and workload allow, accompaniment at the funeral. o Accompaniment of survivors on their return home after discharge. This activity can be shared with the community psychologist. o Accompaniment and follow up at home of patients admitted to the Home Based Support and Risk Reduction (HBSRR) programme. This activity can be shared with the community psychologist. Accountable to: The Psychologist for Inpatient Activities is accountable to the Medical Coordinator in the capital, and the Psychological & Psychosocial Coordinator in the field 266 Annex 15.15 Community Activities Psychologist Objective of the post: Provides psychological care to patients and their families in the community, and supports the outreach activities performed by the mobile teams. Responsibilities: The Psychologist is aware of the risks involved in performing his/her duties. The Psychologist follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. General Responsibilities o Takes every opportunity to inform and sensitise patients, relatives, staff members and the population. o Informs the coordinator regarding any staff member in the event of psychological difficulties. o Provides technical support to the mental health team as required. o Participates in medical coordination meetings, and mental health team meetings. o Attends and participates actively in weekly staff meeting. Psychological and Psychosocial Activities o Provides support for activities carried out by the mobile teams; including burials, home disinfection, and transfer of patients to the health structure. Informs the patient and family regarding the procedures and the activity. Informs the community about the activity with the objective of reducing fear and avoiding potential stigmatisation of victims. Accompaniment, emotional containment, and support while the activity is being performed. o Makes home visits to the families of VHF patients including: Delivery of Solidarity Kit (compensation). Psychological support facilitating emotional expression and the grieving process. Follow up in the event of detecting possible psychological sequelae. o Ensures psychological concerns and interventions are recorded in the individual patient files. o Accompaniment of families in the event of the patient dying at home or in the Treatment Unit. Collaborates with the family in preparation for the funeral. If time and workload allow, accompaniment at the funeral. o Accompaniment of survivors on their return home after discharge. This activity can be shared with the inpatient psychologist. o Accompaniment and follow up at home of patients admitted to the Home Based Support and Risk Reduction (HBSRR) programme. This activity can be shared with the Inpatient Psychologist. Accountable to: The Psychologist for Community Activities is accountable to the Medical Coordinator in the capital, and the Psychological & Psychosocial Coordinator in the field 267 Annex 15.16 Health Promotion/Social Mobilisation Coordinator Objective of the post: Ensures that all health promotion activities are Responsibilities: The Coordinator is aware of the risks involved in performing his/her duties. The Coordinator follows all regulations concerning infection control and protective measures. Non-adherence to the safety regulations can result in immediate dismissal. General Responsibilities o Responsible for all health promotion and social mobilisation activities linked to the outbreak intervention. o Recruits and trains heath promotion and social mobilisation team. o Monitors activities of other actors working on health promotion and social mobilisation to ensure coordination and complementarity of messages and activities. o Plans and supervises activities of the health promotion team. o Takes every opportunity to inform and sensitise the population when working in the field. o Participates in interagency meetings dealing with health promotion and social mobilisation issues. o Attends and participates actively in weekly staff meeting. Health Promotion/Social Mobilisation Activities o Carry out initial socio-cultural investigation and analysis. Investigate the communication means available locally. Investigate level of knowledge of the disease within the population and health staff. Design 1st phase health and operational messages, and the method(s) of delivery. Inform team of any pertinent findings that could affect the intervention and the approaches. o Carry out in-depth socio-cultural analysis. Design the 2nd phase health and operational messages, and the methods of delivery. Inform team of any findings that could affect the intervention, or indicate the need to modify activities or approaches. Advise team on the most appropriate information and messages to deliver in their work. o Carry out health promotion and social mobilisation activities: To increase knowledge and understanding. To encourage changing risky behaviours. To adopt safe practices. o If necessary, accompany mobile teams to carry out informal health promotion activities with families and neighbours of patients. Accountable to: The Health Promotion/Social Mobilisation Coordinator is accountable to the Medical Coordinator in the capital, and the Project Coordinator in the field. 268 Annex 15.17 Example of Ambulance Team Task Description Team members: One Driver One Supervisor (expatriate or local) One Sprayman Two Stretcher Bearers. Objective: Suspect VHF patients are collected and transported to the VHF Treatment Unit in a safe and secure manner. All tasks are carried out in a way that is safe for the team, for other staff, the patient, the family, and the community. Responsibilities of all team members: All members of the team understand the risks related to their work. All members of the team, except for the driver, wear scrub suit when leaving the VHF Treatment unit and put on full protective clothing at the patient’s home before collecting and transporting them. All members of the team are responsible for checking the condition of their reusable equipment every day and replacing items when required. Responsibilities of Team Supervisor: Supervisor leads the team. Supervisor is responsible for the safety and security of all team members. Supervisor ensures that the material required for the intervention is ready and available (using checklist). Supervisor ensures that all protective equipment is worn correctly, and that all procedures are done safely. Supervisor discusses with the patient and the family of the patient: o Explains reasons for the need to isolate the patient. o Explains the procedure for disinfection, transport of the patient and admission to VHF Treatment unit. o Invites one family member to accompany patient to the VHF Treatment unit. Responsibilities of Driver: Driver remains in the cab of the car at all times. Driver must drive carefully and slowly at all times. Responsibilities of Stretcher Bearers: Assist the patient to move on to the stretcher or assist the patient to walk to the car if able to walk. Carry the stretcher to the car, and from the car into the VHF Treatment unit. Stretcher-bearers ensure the patient is comfortable before leaving and during transportation. Responsibilities of Sprayman: Ensures that the sprayer is full of 0.5% chlorine solution. Enters patient room first and disinfects entrance area and area around patient. Explains to other team members the layout of the room, location of bed/patient, and any potential hazards in the room. 269 Disinfects hands, feet, and aprons of team members during the work. Disinfects car, stretcher, and items accompanying patient. Responsible for disinfection during undressing of other team members. Accountable to: The ambulance team is accountable to the MSF mobile team coordinator. Working hours: Two shifts will operate 7 days per week: 0800 - 1300 1300 - 1800 270 Annex 15.18 Example of Burial Team Task Description Team members: One Driver One Supervisor One Sprayman, Two Stretcher Bearers Objective: Bodies of suspect and probable VHF patients are collected and transported to the cemetery in a safe and secure manner. Collection, transportation, and burial are done in a sensitive and culturally acceptable manner. All tasks are carried out in a way that is safe for the team, for other staff, the family, and the community. Responsibilities of all team members: All members of the team understand the risks related to their work. All members of the team, except for the driver, wear scrub suit and gloves to handle and transport the closed coffin, and full protective clothing only when disinfecting, collecting and transporting bodies. All members of the team are responsible for checking the condition of their reusable equipment every day and replacing items when required. Responsibilities of Team Supervisor: Supervisor leads the team. Supervisor is responsible for the safety and security of all team members. Supervisor ensures that the materials required for the burial are prepared and loaded on the vehicle. Supervisor ensures that there are always spare kits of protective clothing ready and available in the vehicle. Supervisor ensures that all protective equipment is worn correctly. Supervisor ensures that all procedures are done safely. Supervisor discusses with the family of the patient: o Explains reasons for the need to bury the body in a safe way. o Explains the procedure for disinfection, use of body bag and coffin, transportation of the body and burial at the cemetery. o Invites one family member to accompany patient to the cemetery. Responsibilities of Driver: Driver remains in the cab of the car at all times. Driver must drive carefully and slowly at all times. Driver uses hazard-warning lights when transporting body. Responsibilities of Stretcher Bearers: Packing the body, used clothes and bedclothes, etc. inside the body bag. Loading the body bag into the coffin (if used) and carrying it to the vehicle. At cemetery: unloading coffin, carrying to gravesite, and lowering into grave. Responsibilities of Sprayman: Ensures that the sprayer is full of 0.5% chlorine solution before starting. 271 Enters room first and disinfects entrance area, and the area around body. o Explains to other team members the layout of the room, location of bed and body, and any potential hazards in the room. Sprays the body, bed and bedclothes, and any other potentially contaminated items near to the body. Sprays outside of body bag after stretcher-bearers have placed body in body bag. Disinfects hands, feet, and aprons of team members during the work. Disinfects the coffin. Disinfects car and stretcher. Responsible for disinfection during undressing of other team members. Accountable to: The ambulance team is accountable to the MSF mobile team coordinator. Working hours: Two shifts will operate 7 days per week: 0800 - 1300 1300 - 1800 272 Annex 15.19 Example of VHF Ward Support Staff Task Descriptions Laundry Workers Collect dirty laundry from changing room o Disinfect in 0.05% chlorine solution for 30 minutes, rinse with water, and wash with detergent and rinse with water. Hang on drying line Take down dry clothes and fold Give clean, dry clothes to changing room cleaner Low-risk Area & Changing Room Cleaner First thing in the morning cleans the family tent at the patient entrance. Arranges scrub suits on shelves according to the different sizes. Ensures boot are kept tidy and in order. Cleans the floor of the changing room. Ensures there are sufficient gloves and scrub suits available. Cleans floor of veranda and pharmacy. Cleans low-risk area compound. Sprays latrines with 0.5% chlorine solution. Fills the water filter. Collects patients’ food from kitchen. Chlorine Preparation and Water Carrier Changes or refills the 0.5% and 0.05% chlorine solutions in the low-risk zone. Changes or refills the drums with the appropriate chlorine solutions: o 0.05% for hand washing. o 0.5% for goggles and outside footbath and sprayer. Fill the drum to rinse goggles with clean water. In the wards, change the 0.5 % solution in the basins next to patients’ beds twice a day. Recover the green gloves from the undressing area and wash them with 0.5% solution. Ensure that there are no holes in them; discard any that are damaged. High-risk Area Cleaner Clean the floors twice per day with 0.5% chlorine solution. Every 2 days, clean the floors with soap and rinse. Help the chlorine preparer to fill the buckets outside the wards with water to prepare the 0.5% chlorine solutions. Fill inside footbath, sprayer and bucket for soaking aprons with 0.5% chlorine solution. Remove waste bags from the wards and undressing area and give them to the waste manager to burn. If required, assist the nurse with collecting and laundering patients’ clothing. Waste Manager Collect the waste from the low and high-risk area. Burn the waste. Ensure the door of the waste area remains closed. Collect, clean and disinfect the patients’ bedpans. Disinfect latrines. At dusk: put kerosene lamps at latrines. 273 Sprayer Fill the sprayers with 0.5% chlorine. Assist the high-risk team with cleaning and disinfection. Spray the beds and mattress with 0.5% chlorine. Spray mobile teams when entering and leaving the unit. Every Monday, Wednesday, Saturday thoroughly clean and maintain the sprayers. Assist people with disinfection when undressing. Timetable for Support Staff Adapt as required. Morning Shift Position Changing Work outside Work inside Rest out Work out Chlorine Preparation 0800 – 0830 0830 – 1000 1000 – 1200 1200 – 1230 1230 – 1400 Sprayer 0800 – 0830 0900 – 1130 1130 – 1200 Cleaners 0800 – 0830 0830 – 1100 1100 – 1200 1200 – 1330 if required Waste manager 0800 – 0830 0830 – 1100 1100 – 1200 1200 – 1330 if required Work inside 1200 – 1330 Afternoon Shift Position Changing Work outside Work inside Rest out Work out Chlorine Preparation 1200 – 1230 1230 – 1400 1400 – 1600 1600 - 1630 1630- 1800 Sprayer 1200 – 1230 1300 – 1530 1530 – 1600 Cleaners 1200 – 1230 1230 – 1500 1500 – 1530 1530 – 1730 if required Waste manager 1200 – 1230 1230 – 1500 1500 – 1530 1530 – 1730 if required Work in 1600 – 1730 Back to Table of Contents 274 Annex 16 Main Intervening Organisations in Filovirus Outbreaks WHO Communicable Disease Surveillance and Response (CSR). WHO, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland. Tel. (41 22) 791 2909; Fax (41 22) 791 4198 E-mail: csr@who.int or outbreak@who.int Global Outbreak Alert and Response Network (GOARN) E-mail: goarn@who.int Ministry of Health See locally for contact details. CDC National Center for Infectious Diseases Division of Viral and Rickettsial Diseases, Special Pathogens Branch, 1600 Clifton Road, MS G-14 Atlanta, Georgia 30329-4018, USA. Tel: 00 1-404-639-1115 Fax: 00 1-404-639-1118 Email: CJP0@CDC.GOV National Microbiology Laboratory Health Canada, Winnipeg, Canada. Tel: 00 1-204-789-6019 Fax: 00 1-204-789-5097 Email: Heinz_Feldmann@phac-aspc.gc.ca Institut Pasteur 28, rue du Dr Roux, 75724 Paris, Cedex 15, France. Tel: 00 33 1 406 13088 Fax: 00 33 1 406 13151 Coordination – International and National Health Authorities and Coordination Confirmation of outbreak, laboratorytesting, possible fieldwork and research, and possibly field laboratory. Field laboratory and research. Confirmation of outbreak, laboratorytesting, possible fieldwork, and research. 275 National Institute for Virology Special Pathogens Unit, Private Bag X4, Sandringham 2131, Zaloska 4, South Africa. Tel: 00 27-11-882-9910, 00 27-11-3214200 Fax: 00 27-11-882-0596, 00 27-11-8820596 Institute of Tropical Medicine Antwerp, Belgium. Tel: 00 32-3-247-66-66 Fax: 0032-3-216-14-31 Phillips University: Institute of Virology Marburg, Germany. Tel: Fax: Email: Annex 16.1 Confirmation of outbreak, laboratorytesting, possible fieldwork, and research. Possible fieldwork and research. Confirmation of outbreak, laboratorytesting, possible fieldwork, and research. Main Filovirus Testing Centres Centre for Disease Control and Prevention (CDC) National Center for Infectious Diseases Division of Viral and Rickettsial Diseases, Special Pathogens Branch, 1600 Clifton Road, MS G-14 Atlanta, Georgia 30329-4018, USA. Tel: 00 1-404-639-1115 Fax: 00 1-404-639-1118 Email: CJP0@CDC.GOV National Institute for Virology Special Pathogens Unit, Private Bag X4, Sandringham 2131, Zaloska 4, South Africa. Tel: 00 27-11-882-9910, 00 27-11-3214200 Fax: 00 27-11-882-0596, 00 27-11-8820596 US Army Medical Research Institute of Infectious Diseases (USAMRIID) Fort Detrick, Maryland 21 702-5011 USA. Division of Pathology Centre for Applied Microbiology and Research Porton Down, Salisbury, Wiltshire SP4 0JG, UK. Tel: 00 1 404 639 1115 Fax: 00 1 404 639 1118 Tel: 00 44 198 061 2224 Fax: 00 44 198 061 2731 Institut Pasteur 28, rue du Dr Roux, 75724 Paris, Cedex 15, France. Bernard-Nocht Institut Bernhard-Nochtstrasse 74 D-20359 Hamburg 4, Germany. 276 Tel: 00 33 1 406 13088 Fax: 00 33 1 406 13151 Tel: 00 49 40 31 18 24 60 Fax: 00 49 30 31 18 23 78 Back to Table of Contents 277 Annex 17 MSF CODE KMEDZTF0065 KMEDZTF0066 1 DEXTIODP1S2 2 DEXTCHLC1S1 3 DORAAMOX2T- 4 DORACHLO2C- 5 DORADOXY1T- 6 DORAMETN2T- 7 DORACOTR4T- 8 DORAPARA1T- 9 DORAPARA5T- 10 DORACIPR5T- 11 DORAPROM2T- 12 13 DORAASCA2T- 14 DORARETI2T- 15 DORAORSA1S- 16 DORAORMA2S4 17 DORACHLM2T- 18 DORAZTF0100 19 DORAARTS5T- Contents of Viral Haemorrhagic Fever Kits DESCRIPTION Technical supplementary specifications QTY REMARKS / USAGE Viral Haemorrhagic Fever Kit, 10 beds/10 days Kit Fièvres Hémorragiques Virales, 10 lits/10 jours MODULE 1 – DRUGS; MEDICAMENTS IODE POVIDONE, 10%, solution, 200 ml, fl. Verseur; IODINE POVIDONE, 10%, solution, 200 ml, dropper bot. CHLORHEXIDINE 1,5% + CETRIMIDE 15%, solution, 1 l, fl. CHLORHEXIDINE 1.5% + CETRIMIDE 15%, solution, 1 l, bot. AMOXICILLINE, 250 mg, comp. secable AMOXYCILLIN, 250 mg, breakable tab. CHLORAMPHENICOL, 250 mg, gel. CHLORAMPHENICOL, 250 mg, caps. DOXYCYCLINE, 100 mg, comp. DOXYCYCLINE, 100 mg, tab. METRONIDAZOLE, 250 mg, comp. METRONIDAZOLE, 250 mg, tab. COTRIMOXAZOLE, 400 + 80 mg, comp. secable COTRIMOXAZOLE, 400 + 80 mg, breakable tab. PARACETAMOL (acétaminophène), 100 mg, comp. PARACETAMOL (acetaminophen), 100 mg, tab. PARACETAMOL (acétaminophène), 500 mg, comp. PARACETAMOL (acetaminophen), 500 mg, tab. CIPROFLOXACINE CHLORHYDRATE, 500 mg, comp. CIPROFLOXACINE HYDROCHLORIDE, 500 mg, tab. PROMETHAZINE CHLORHYDRATE, 25 mg, comp. PROMETHAZINE HYDROCHLORIDE, 25 mg, tab. Vitamin B complexe ASCORBIQUE ACIDE, 250 mg, comp. ASCORBIC ACID, 250 mg, tab. RETINOL (vitamine A), 200.000 UI, stabilisé, perle RETINOL (vitamine A), 200,000 IU, stabil., soft gelat. caps. SELS DE REHYDRATATION, (S.R.O.), sachet 27,9 g/1 l ORAL REHYDRATION SALTS (O.R.S.), sachet 27.9 g/1 l ReSoMal, melange réhydratant, sachet 420g/10l; ReSoMal, rehydration mix, bag 420g/10l; CHLORPROMAZINE CHLORHYDRATE, 25 mg, comp. CHLORPROMAZINE HYDROCHLORIDE, 25 mg, tab. TRAMADOL, 50 mg, gél. TRAMADOL, 50 mg, caps. ARTESUNATE, 50 mg, comp. 5 Antiseptic and disinfectant (medical use) 2 Antiseptic and detergent (medical use) 1000 Antibiotic 1000 Antibiotic 1000 Antibiotic; Combination drug Anti-malaria (Adults) 1000 Antiprotozoal; antibacterial 1000 Antibiotic 1000 Antipyrétique 1000 Antipyrétique 100 Antibiotic 1000 200 Anti-nausea BECOZYME FORTE ® tab. Roche ® (supl B compl.) 1000 Vitamin C 1000 Vitamin A 500 Oral re-hydration 10 Oral re-hydration with extra Potassium. 1000 1000 240 Tranquiliser 1 x 120 tab presentation (Brand) or 1x 1000 presentation (generic) Painkiller Anti-malaria 278 ARTESUNATE, 50 mg, tab. 20 21 DINJZTF0038 22 DINJZTF0019 23 DINJGLUC5V5 24 DINJARTE2A- 25 DINJARTE8A- 26 DINJZTF0020 27 DINJCEFT1V- 28 DINJCHLO1V- 29 DINJZTF0012 30 DINJZTF0004- 31 DINJZTF0030 32 DINJZTF0010 33 DINJWATE1A- 34 DINFRINL1P1 35 DINFRINL1P5 36 DDGTMALF2-- KMEDZTF0073 1 DORADIAZ5T- 2 DINJDIAZ1A- 3 DINJPENA3A- 4 DINJPHEN2A1 METOPIMAZINE (VOGALENE ®) 10mg/ml Amp. 100 TRAMADOL HYDROCHLORIDE, 50 mg/ml, 2 ml, amp. TRAMADOL CHLORHYDRATE, 50 mg/ml, 2 ml, amp. POTASSIUM CHLORURE, 100 mg/ml, 10 ml, amp POTASSIUM CHLORIDE, 100 mg/ml, 10 ml, amp.. GLUCOSE HYPERTONIQUE, 50%, 50 ml, fl. GLUCOSE HYPER, 50%, 50 ml, vial ARTEMETHER, 20 mg/ml, 1 ml, amp. ARTEMETHER, 20 mg/ml, 1 ml, amp. ARTEMETHER, 80 mg/ml, 1 ml, amp. ARTEMETHER, 80 mg/ml, 1 ml, amp. CEFTRIAXONE, 250 mg, fl. Poudre + solvant IM CEFTRIAXONE, 250 mg, powder, vial + IM solvant CEFTRIAXONE, 1 g, fl. poudre CEFTRIAXONE, 1 g, powder, vial CHLORAMPHENICOL, 1 g, fl. poudre CHLORAMPHENICOL, 1 g, powder, vial SODIUM BICARBONATE, 8.4%, 1 Meq/ml, 20 ml, amp. SODIUM BICARBONATE, 8,4%, 1 Meq/ml, 20 ml, amp. CHLORPROMAZINE, 25 mg/ml, 2 ml, amp. CHLORPROMAZINE, 25 mg/ml, 2 ml, amp. PROPACETAMOL, 1 g, amp + 5 ml solvent; PROPACETAMOL, 1 g, amp + 5 ml solvent. FUROSEMIDE, 10 mg/ml, 2 ml, amp. FUROSEMIDE, 10 mg/ml, 2 ml, amp. EAU pour injection, 10 ml, amp. plastique WATER for injection, 10 ml, plastic amp. RINGER LACTATE, 1 l, poche plastique + PERFUSEUR RINGER LACTATE, 1 l, plastic pouch, + SET RINGER LACTATE, 500 ml, poche plastique + PERFUSEUR RINGER LACTATE, 500 ml, plastic pouch, + SET TEST, MALARIA, Pf, rapide (Paracheck), device, 25 tests, kit TEST, MALARIA, Pf, rapid (Paracheck), device, 25 tests, kit 20 Analgesic 21 Anti- hypokalaemia; Anti-nausea; 5 Energy boost; 10 Anti-malaria; 18 Anti-malaria; 10 Antibiotic; 50 Antibiotic; 100 Antibiotic; 12 Anti metabolic acidosis 20 Tranquiliser 100 10 = Paracetamol injectable Antipyrétique Diuretic 200 300 Intravenous re-hydration; 24 Intravenous re-hydration; 1 MODULE 1b DRUGS; MEDICAMENTS DIAZEPAM, 5 mg, comp. DIAZEPAM, 5 mg, tab. DIAZEPAM, 5 mg/ml, 2 ml, amp. DIAZEPAM, 5 mg/ml, 2 ml, amp. PENTAZOCINE, 30 mg/ml, 1 ml, amp. PENTAZOCINE, 30 mg/ml, 1 ml, amp. PHENOBARBITAL SODIUM, 200 mg/ml, 1 ml, amp. PHENOBARBITAL SODIQUE, 200 mg/ml, 1 ml, amp. 1000 Tranquiliser; 100 Tranquiliser; 100 Painkiller; 100 Anti convulsant 279 5 DORAZTF0106 KMEDZTF0067 1 SMSUDEPT1W- 2 EMEQBOTP1-- 3 EMEQBRUS1-- 4 SDRECOTW5R- 5 SDRECOMP1N- 6 SDRECOMP1S- 7 SMSUCOND1A- 8 EMEQTOUR1-- 9 10 EMEQBEDP1-- 11 EMEQKIDD26- MORPHINE SULFATE, 10 mg, gel., LP MORPHINE SULPHATE, 10 mg, caps. slow release Asta Medica ® Painkiller; Morphine sublinguale slow release MODULE 2 - MEDICAL MATERIAL; MATERIEL MEDICAL ABAISSE LANGUE; Tongue depressor. BOUTEILLE, plastique, 1 l, pour dilution + bouchon a visser; BOTTLE, plastic, 1 l, for dilution + screw cap BROSSE A ONGLES, plastique, autoclavable; NAIL BRUSH COTON hydrophile, ROULEAU, 500 g; COTTON WOOL, hydrophillic, ROLL, 500 g COMPRESSE DE GAZE, 10 cm, 12 plis, 17 fils, NON STERILE; Gauze 10 x 10 Non sterile COMPRESSE DE GAZE, 10 cm, 12 plis, 17 fils, STERILE; Gauze 10 x 10 sterile CONTRACEPTIF MASCULIN, lubrifie + RESERVOIR, taille A CONDOM, lubricated + RESERVOIR, size A GARROT elastique, 100 x 1,8 cm; TOURNIQUET, rubber band, 100 x 1.8 cm Tire-lait manuel; Manual Breast milk pump BASSIN DE LIT, inox; BEDPAN, stainless steel. BASSIN RENIFORME, 26 cm x 14 cm, inox (haricot); KIDNEY DISH, 26 cm x 14 cm, stainless steel. BOITES A RECUPERATION AIGUILLES 4L (plastique); SHARPS CONTAINER, 4L (plastic) 12 168 100 2 1 for suspect cases ward and 1 for confirmed cases ward. 30 Bare hand washing at changing room 1. Discard after each shift. 2 1 for suspect cases ward and 1 for confirmed cases ward. 500 50 720 For discharged recovered patients, to use up to 90 days after discharge. 4 2 Disinfectable model. To relieve breast "clogging". Disinfectable model. 10 Disinfectable model (INOX or PLASTIC) Disinfectable model (INOX or PLASTIC) 10 10 MERCK Eurolab ® HUAR 200 Must be disposed of safely. 4L; Disinfectable & washable (PVC) Disinfectable & washable (PVC) 13 EHOESTRT2-- BRANCARD PLIANT en long/large, alu, 4 pieds, 220 x 58 cm; STRETCHER, TARPOLIN 6 14 AFURZTF0008 2 1 for suspect- and 1 for confirmed cases ward (pulse taking). 15 PLIGLAMPS4- 3 Recharge lamp inside the risk-zone it is used in. At least 1 for suspect- and 1 for confirmed cases ward. 16 PLIGLAMPT1- 2 For medical doctors; (examination) . 17 SMSUBAGP06- 18 SDRETAPA025 19 EMEQSPHY1A- 20 EMEQSPHY1P- HORLOGE MURALE; WALL CLOCK LAMPE SOLAIRE, BP solar SL48, portable; SOLAR LAMPS BP SOLAR 48 LAMPE TORCHE, Maglite Mini, étanche, piles type R6 LAMP, TORCH, Maglite Mini, waterproof, R6 battery type SACHET plastique, pour médicaments, 6 x 8 cm ; BAG, plastic, for drugs, 6 x 8 cm SPARADRAP, oxyde de zinc, ROULEAU, 2 cm x 5 m; TAPE, ADHESIVE, zinc oxide, ROLL, 2 cm x 5 m SPHYGMOMANOMETRE, manopoire, velcro, adulte ; SPHYGMOMANOMETER, hand manometer, velcro, adult SPHYGMOMANOMETRE, manopoire, velcro, enfant; SPHYGMOMANOMETER, hand manometer, velcro, pediatric 100 4 4 Disinfect properly between (suspect) cases. 2 for suspect- and 2 for confirmed cases ward 4 Disinfect properly between (suspect) cases. 2 for suspect- and 2 for confirmed cases ward 280 21 EMEQSTET2-- 22 SMSUTHER1R- 23 ESURSCIS24- 24 SINSIVPU18- 25 SINSIVPU20- 26 SINSSCAV25- 27 SINSSYRD10- 28 SINSSYRD02- 29 SINSNEED19- 30 SINSNEED21- 31 SINSNEED23- KMEDZTF0068 1 ELINTROS1W- 2 ELINTUNS1W- 3 STETHOSCOPE, double face, clinicien; STETHOSCOPE, double cup, clinician THERMOMETRE, rectal, Celsius, + etui de protection ; THERMOMETER, rectal, Celsius, + protecting cover SCISEAUX DE LORENZ, courbes, 24 cm 40-13-24 SCISSORS, LORENZ, curved, 24 cm 40-13-24 12 Personalise. Disinfect properly after each use. 20 1 per patient, must be AXILLARY ONLY. Disinfect properly after each use. CATHETER COURT IV, 18 G, (1,3 x 45 mm), vert; IV PLACEMENT UNIT (cathether), 18G CATHETER COURT IV, 20 G, (1,1 x 32 mm), ROSE; IV PLACEMENT UNIT (cathether), 20G AIGUILLE A AILETTES, epicranienne, 25 G (0,5 x 19 mm) ; SCALP VEIN INFUSION SET, 25 G (0.5 x 19 mm), orange SERINGUE, u.u., Luer, 10 ml SYRINGE, disposable, Luer, 10 ml; SERINGUE, u.u., Luer, 2 ml SYRINGE, disposable, Luer, 2 ml; AIGUILLE, u.u., Luer IV, 19 G (1,1 x 40 mm), creme NEEDLE, disposable, Luer IV, 19 G (1.1 x 40 mm), cream 10 AIGUILLE, uu., Luer IM, 21 G; NEEDLE, disposable, Luer IM, 21 G (0.8 x 40 mm), green. ; AIGUILLE, uu., Luer SC, IM enfant, 23G; NEEDLE, disp., Luer SC, IM child, 23 G (0.6 x 30 mm), blue. ; 2 LORENZ Ciseaux à pansements, Courbés, 24 cm de long, MEDICOM INSTRUMENTE® ref. 40.13.24 20 50 200 400 300 200 200 MODULE 3 - PROTECTION MATERIAL; MATERIEL de PROTECTION PANTALON CHIRURGICAL, tissé TROUSERS, SURGICAL, woven TUNIQUE CHIRURGICALE, tissée TUNIC, SURGICAL, woven 100 1 per shift for each isolation worker, and members of the ambulance & burial teams (= trousers of scrub suit). 100 1 per shift for each isolation worker, and members of the ambulance & burial teams (= blouse of scrub suit). GANTS DE MENAGE, caoutchouc, reutilisable (la paire) ; 400 "GREENFIT PLUS" (Hospitera) Used as second pair of gloves for sprayer, ambulance teams, and for GLOVES, CLEANING, rubber, reusable, (pair) GANTS de protection renforcée,latex, reutilisable (la paire) ; 4 1 for each dressing room 20 MAPA® professionnel. Trident ref. specific heavy duty jobs. For laundry, burial teams. 285.31 GLOVES, protection, latex, reusable, (pair) 10 Pairs nr 8 and 10 pairs nr 10. 5 GANTS D'EXAMEN HAUT RISQUE, usage unique, ; HIGH RISK EXAMINATION GLOVES, disposable, 4000 Nitra Tex EP ref 4400042 Ansell Medical ® Basic glove for every person inside isolation unit (Low- and High-risk zones), 1000 pce Small; 2000 pce Medium ; 1000 burial- and ambulance teams. pce Large 6 GANTS CHIRURGICAUX, Latex uu paire; GLOVES SURGICAL disposable Pair 1000 400 Pairs SMSUGL0S7-AND 600 Pairs SMSUGL0S8-- 7 8 9 SDREBANC103 BANDAGE, COHESIVE, elastic, 10 cm x 3 m BANDE COHESIVE, élastique, 10 cm x 3 m SALOPETTE de PROTECTION; PROTECTIVE OVERALL CASAQUE CHIRURGICALE.uu., avec manches longues; GOWN, DISPOSABLE with long sleeves 30 700 336 For sensitive jobs inside High-risk zone (e.g. pulse taking). For securing fitting of wrist band of gown with edge of glove. Mao collar welded overall. Topguard (= same use as gown) ®; Tyvek-Pro.Tech ® -- NON STERILE HARTMANN ® 168 Pce XL and Use for example in certain circumstances, such as cultural restrictions (women wearing overall / trousers..) 168 Pce XXL. Cut bottom if too long. 281 10 ELINAPRS1R- 11 12 ELINMASP1HF 13 14 15 16 17 DEXTTALC1P1 18 19 20 21 SMSUBAGB2W- KMEDZTF0069 1 PLIGLAMPS4- 2 EHOEMATT1C- 3 PPACBAGP1B- 4 5 6 CWATCONT20F 7 CWATCONT20T TABLIER PROTECTION, plastique HEAVY DUTY; APRON PROTECTION, plastic HEAVY DUTY BOTTES, caoutchouc, (pair) BLANC; BOOTS, rubber, (pair) WHITE 50 APRON SURGICAL, rubber Bright colour. Personalise by writing names on it. 50 5 x nr 37; 10 x nr 39; 10 x nr 41; 20 x nr 43; 5 x nr 44. Personalise by writing names on it. MASQUE DE PROTEC., RESP.(PCM2000 FLUIDSHIELD) haute filtra; MASK, PROTECTION, RESP.(PCM2000 FLUIDSHIELD) high filtration 1300 COIFFE avec masque a six lacets incorporé; CAP (HOOD) with 6 laces mask COIFFE CHIRURGICAL u.u.; SURGICAL CAPS Disposable 1000 500 Orthopédique non tissé polypropylène souple et leger EVERCAP® REF C12; Code 686408BD (Hospitera) LUNETTES DE PROTECTION, plastique (GOGGLES), ; GOGGLES, PROTECTIVE, plastic SPRAY anti-Buée (Trident, 2 ounce spray, #LP80); Anti-FOG spray (Trident, 2 ounce spray, #LP80) TALC, poudre; 1 kg; TALC, powder ,1 kg MIROIR; +/- format A4; MIRROR +/- format A4 MIROIR a poignet (portable); Hand MIRROR ALESE 60 x 60 cm uu; BED (under) PADS 60 X 60 cm disposable 150 FLEXY wraparound Goggles BS 2092,2 CDM = diving spray (Trident, 2 ounce spray, #LP80) SAC, plastique, mortuaire, blanc, 150 microns, 220 cm; BAG, body, plastic, white, 150 microns, 220 cm 40 10 Put this mask as first mask under the incorporated mask of the Tyvec headcover. Topguard ®; Tyvek-Pro.Tech ® -- NON STERILE 2 2 Use to diminish fogging of goggles. To ease putting gloves on. FORMAT A4 (For Transport reasons) 1 500 Personalised. Use anti-fog spray provided in same module of kit. To be installed side by side in changing room 2. To allow checking if protective gear is well adjusted (closings of protective gear on back) (Pulp onderlegger (normal) 60x60 IDA) Art. nr.168 367 UTERMOHLEN MEDICAL CARE via IDA For cleaning up spills and liquid waste. With long enough ZIPPER TAB to be able to open and close it with two pairs of gloves!!!! Check zipper tab before starting burial procedure. If too short, put little lace to zipper tab before starting burial procedure. Use double if no coffin. MODULE 4 - LOGISTICS & SANITATION; LOGISTIQUE & SANITATION LAMPES SOLAIRES BP SOLAR 48; SOLAR LAMPS BP SOLAR 48 HOUSSES POUR MATELAS (PVC); MATTRESS COVERS (PVC) SAC, poubelle, plastic, 100 l, noir, 70 microns ; BAG, dustbin, plastic, 100 l, black, 70 microns SUPPORT POUBELLE 100 l; GARBAGE STAND TIR BOTTES; BOOT REMOVER NOURRICE A EAU, 20 l pliable bouchon d. 5 cm plast. alim. ; 3 10 Recharge lamp inside the risk-zone it is used in. Bright colour (White); Disinfectable. 300 5 1 For suspect- and confirmed cases. Use double for wet and organic waste. Garbage=sack holder with cover 60130L ARTEX ® (Model with One Holder ) DISINFECTABLE Foldable model. If more are needed , make locally. For changing room 1 If more are needed , make locally. 5 Diverse use possible 5 Diverse use possible CONTAINER, WATER, 20 l collaps., 5 cm cap, food grade plast (nourrice à eau pliable 20 l) ROBINET, pas de vis 5 cm ; (collapsible water container 20 l) TAP, screw type 5 cm diam 282 8 CSHEBLAN5W- 9 PCOOBOWL2RP 10 11 12 13 14 15 16 CWATBUCK14L 17 CWATBUCK20L 18 CWATCONT12L 19 CWATSPRA12- 20 CWATSPRA13G 21 COUVERTURE; BLANKET BASSINE, 20L, plastique, ronde ; BASSINE, plastic, 20 l, round GOBELETS, Plastique; DRINKING CUPS, plastic ASSIETTES (Plastique); EATING PLATES, (Plastic) CUILLERS A SOUPE desinfectable ; Disinfectable TABLE SPOONS JERRY CANS 5 L, plastique; JERRY CANS 5 L, plastic SEAU, plasique, 10 l COULEUR VERT + COUVERCLE; Bucket 10 l plastic; GREEN COLOR + LID SEAU, plasique, 10 l COULEUR JAUNE + COUVERCLE; Bucket 10 l plastic; YELLOW COLOR + LID SEAU, plast. alimentaire, 14 l, gerbable + COUVERCLE; Bucket 14 l SEAU, plast. alimentaire, 20 l, carre,+ COUVERCLE ; BUCKET, food grade plastic 20 l, square + LID BAC plastique, 125 l, forme carree, gerbable + COUVERCLE & ROBINET; WATER CONTAINERS 125 L + LID & TAP PULVERISATEUR, 12 l, IK 12BS; SPRAYER, 12 l, IK 12BS (pulvérisateur 12 l, IK 12BS) JOINT de rechange ; (sprayer,12 l, IK 12BS) spare GASKET PULVERISATEUR 1l, plastique SPRAYER 1L Plastique CUILLER A SOUPE, plastique, 15 grammes; PLASTIC TABLE SPOONS 15 gr plastic HYPOCHLORITE de CALCIUM (HTH) 70% granules 500 g embal. IATA; HTH 70% IATA PACKING 22 CWATZTF0104 23 CWATYCAH7G5 24 KWATKCHL01- KIT, CHLORATION & CONTROLE EAU (10.000 personnes/1 semaine); KIT, CHLORINATION & WATER CONTROL (10.000 pers/1 week). 25 DEXTSOAP1B2 SAVON, 200 g, barre; SOAP, 200 g, bar EPONGE; SPONGE 26 27 KCAMMINS01C 28 CSHEPLASW4W 29 CSHEROPE05P 30 ASTAPENM3BB MODULE INSTALLATION CAMP, et balisage; MODULE, CAMP INSTALLATION and boundary PLASTIC SHEETING, tissé, 4x60m, blanc/blanc, 6 bandes, roul.; PLASTIC SHEETING, 4 x60m white, 6 bands, roll CORDE, diam. 5mm, POLYPROPYLENE, fibre continue (m); ROPE, diam. 5 mm, POLYPROPYLENE endless fibres (per 30 20 Also used for water collecting under hand washing tap stand. 20 cfr. Kit Nut 20 cfr. Kit Nut 20 10 Easy to follow-up ORS consumption per patient . 15 Used for collecting laundry of patients. 15 Used for collecting liquid waste (vomit, spills…). 15 Diverse use possible 5 Diverse use possible 10 Chlorine solutions, hand washing tap stands. 4 Guard/sprayer and ambulance- and burial teams. 4 Spare parts for 12 l sprayer. 10 Used in cars and as per protocol for disinfecting. 10 For measuring chlorine. 65 KG 1 IATA Packing. Disinfection; Water treatment. Standard MSF chlorination kit. (Disinfection; Water treatment). 30 Hand washing; Laundry. 10 Disinfection of aprons by dipping. 1 Standard MSF-module. Set up of isolation unit (outside and inside fencing) 2 Set up of isolation unit (outside and inside fencing); Diverse use. 500 m Set up of isolation unit; Diverse use. m) MARQUEUR, noir, indélébile, géant, pointe carrée ; MARKER, black, permanent, large, square tip 5 283 31 PPACTAPE1M- RUBAN ADHESIF, MSF, PVC (rouleau); TAPE, adhesive, MSF, PVC (roll) 32 CSHETAPE2BF 33 ASTAPAPE5B- RUBAN DE BALISAGE, blanc/orange, fluorescent, rouleau 500 m ; TAPE, BOUNDARY marking, white/orange, fluorescent, roll 500m PAPIER pour PAPERBOARD, 50 feuilles, le rouleau; FLIP CHART PAPER (roll of 50 p) KMEDZTF0070 1 KMEDMSAM1S- 2 ELAEBSVC1P- 3 ELAEBSVV1H- 4 ELAEBSVV21N 5 ELAEBSVV5TP 6 7 8 9 10 SINSSYRD10ELAECONT6U- 11 12 13 ASTASTIC428 KMEDZTF0071 1 2 10 2 Quick pre-fencing of risk zones or isolation unit. 2 Training; identification of diverse risk zones, etc. 5 For blood sampling on filter paper. MODULE 5 – SAMPLING; PRELEVEMENT MODULE PRELEVEMENT SEROLOGIE, transport ; MODULE, SAMPLE, SEROLOGY, transport (système prél.sanguin) RECIPIENT PROTECTEUR ; (blood sampling system) CONTAINER, PROTECTION (s.prél.sang.) CORPS PORTE TUBE (Vacutainer) ; (blds. syst.) HOLDER for VACUUM TUBE (Vacutainer) (s.prél.sang) AIGUILLE, stérile, 21G (Vacutainer); (blds.syst.) NEEDLE, sterile, 21G (Vacutainer) (s.prél.sang.) TUBE SOUS VIDE, SEC, 5 ml (Vacutainer) ; blds.syst.) TUBE, VACUUM, PLAIN, 5 ml (Vacutainer) SKIN-SNIP-BIOPSY-SET (MSF packed) composed of : (1 x POINCON A BIOPSIE USAGE 5mm UNIQUE--SKIN BIOPSY PUNCH 5mm disposable); (1 x SET ENLEVEMENT DE FIL UU; -- SUTURE REMOVAL KIT DISPOSABLE); (2 x RECIPIENT avec FORMOL (min 20 ml); -- VIAL WITH FORMALIN (min 20 ml))) (Liver puncture) Aiguille pour biopsie de tissue (Liver puncture Needle for tissue biopsy 100 For blood sampling. 150 For blood sampling. 100 For blood sampling. 100 For blood sampling. 5 Each set needs to be packed separately. For skin-snip biopsy. 2 Monoject biopsy needle 13G, 3 1/2" Kendall ® code 1100-247194 For liver biopsy (post-mortem) If required to take liver sample, only physicians experienced in biopsies should do this. (Liver puncture) RECIPIENT avec FORMOL (min20 ml); (Liver puncture) VIAL WITH FORMALIN (min 20 ml) 4 SERINGUE, u.u., Luer, 10 ml SYRINGE, disposable, Luer, 10 ml; POT A PRELEVEMENT, urine, plastique, non stérile, 60 ml CONTAINER, SAMPLE, urine, plastic, non-sterile, 60 ml; BOITE, emballage triple, transport Diagnostic Specimen; BOX, triple packing, transp. of Diagnostic Specimen. BOITE ISOTHER, emb. Triple, transp. Diagnostic Specimen; BOX ISOTHERM, triple pack., transp. of Diagnostic Specimen 5 ETIQUETTE, AUTOCOLLANTE, A4, 28 unités 105x25 mm, pr fiches ; STICKER, ADHESIVE, A4, 28 units 105x21 mm, for stock card 20 For liver biopsy (post-mortem) If required to take liver sample, only physicians experienced in biopsies should do this. For urine and stool samples. Respect cold chain for differential diagnosis. 8 For transport of samples of unknown diagnostic. 5 For transport of samples of unknown diagnostic. 800 For identification of samples MODULE 6 - LIBRARY, FORMS & STATIONERY EBOLA BRIEFING MSF 2001 EBOLA READER MSF(when finished) 3 1 MSF- Briefing document & for field use. 284 3 4 5 6 7 L002CLIG01E 8 L003HEFB02E L002CLIG01F L014DRUG01F L014DRUG01E L003HEFB02F 9 10 11 L003ZTF0002 12 ASTAPENM3BB 13 ASTAPENF1BS ASTABOOE2SH CLINICAL GUIDELINES GUIDE CLINIQUE ET THERAPEUTIQUE MEDICAMENTS ESSENTIELS - Guide pratique d'utilisation ESSENTIAL DRUGS - Practical guidelines Controle de l'infection en cas de FIEVRE HEMORRAGIQUE VIRALE en milieu hospitalier africain, OMS/CDC 208 p Infection control of VIRAL HAEMORRAGIC FEVERS in Afr. health. WHO/CDC 198p PROCEDURE DE PRELEVEMENT DE SANG; PROCEDURES FOR BLOOD DRAWNING; CAHIER, 210 x 297 mm, à spirale, quadr. 5 mm, rigide, 180p.; 3 3 3 3 2 MSF standard clinical guideline (English) MSF standard clinical guideline (French) MSF standard essential drugs guideline (French) MSF standard essential drugs guideline (English) Guidelines for Viral Haemorrhagic Fevers (French) 2 Guidelines for Viral Haemorrhagic Fevers (English) 2 2 5 MSF - Guidelines for sampling taking (French). MSF - Guidelines for sampling taking (English). EXER. BOOK, 210x297mm, spiral bind, 5mm sq, hard cover, 180p 10 15 L003ZTF004 MARQUEUR, noir, indélébile, géant, pointe carrée ; MARKER, black, permanent, large, square tip CRAYON FEUTRE, pointe fine, noir; PEN, FELT, black, sharp PAPIER CARBONNE CARBON PAPER Standard Forms for Haemorrhagic Fev. (paper) Eng + fr.Set 16 L003ZTF004 Standard Forms for Haemorrhagic Fev. (disc) Eng + fr., set 1 Set posters of "Dressing protocols". 1 PORTE BLOC, ECRITOIRE, rigide, avec pince et rabat A4; CLIPBOARD A4 plastic CHEMISE, plastique, transparent, perforée, A4 ouvert en haut; Plastic envelopes for forms 10 14 17 18 ASTAHOLD1P- 19 ASTADIVI1PP KMEDZTF0072 1 EMEQTOUR1-- 2 3 DEXTIODP1S2 4 SDRETAPA025 5 EMEQSPHY1A- 6 EMEQSPHY1P- 7 EMEQSTET2-- 8 SMSUTHER1R- 10 200 2 200 pages Epidemiology (Field copy of identification forms) Case and contact definitions (EHF); Case reporting form; Contact recording form; Contact tracing form; Steps for putting ON (& OFF) protective clothing); Clinical data form. Case and contact definitions (EHF); Case reporting form; Contact recording form; Contact tracing form; Steps for putting ON (& OFF) protective clothing); Clinical data form. For changing rooms & training. 100 MODULE 7 - SAMPLING & ASSESSMENT GARROT elastique, 100 x 1,8 cm; TOURNIQUET, rubber band, 100 x 1.8 cm 1 BOITES A RECUPERATION AIGUILLES 4L (plastique); SHARP CONTAINER, 4L (plastic) 2 IODE POVIDONE, 10%, solution, 200 ml, fl. Verseur ; IODINE POVIDONE, 10%, solution, 200 ml, dropper bot. SPARADRAP, oxyde de zinc, ROULEAU, 2 cm x 5 m; TAPE, ADHESIVE, zinc oxide, ROLL, 2 cm x 5 m SPHYGMOMANOMETRE, manopoire, velcro, adulte ; SPHYGMOMANOMETER, hand manometer, velcro, adult SPHYGMOMANOMETRE, manopoire, velcro, enfant; SPHYGMOMANOMETER, hand manometer, velcro, paediatric STETHOSCOPE, double face, clinicien; STETHOSCOPE, double cup, clinician THERMOMETRE, rectal, Celsius, + etui de protection ; 1 MERCK Eurolab ® HUAR 200 Must be disposed of safely. 4L; Antiseptic and disinfectant (medical use). 1 3 Disinfect properly between (suspect) cases. 3 Disinfect properly between (suspect) cases. 3 Disinfect properly between (suspect) cases. 5 Use as AXILLARY thermometer ONLY. 285 THERMOMETER, rectal, Celsius, + protecting cover SDRECOTW5R- COTON hydrophile, ROULEAU, 500 g ; COTTON WOOL, hydrophilic, ROLL, 500 g 1 10 GANTS DE MENAGE, caoutchouc, reutilisable (la paire) ; 3 11 GLOVES, CLEANING, rubber, reusable, (pair) GANTS D'EXAMEN HAUT RISQUE, usage unique, ; HIGH RISK EXAMINATION GLOVES, disposable, 9 12 SMSUGL0S8-- 13 ELINTROS1W- 14 ELINTUNS1W- 15 GANTS CHIRURGICAUX, Latex uu paire; GLOVES SURGICAL disposable Pair PANTALON CHIRURGICAL, tissé TROUSERS, SURGICAL, woven TUNIQUE CHIRURGICALE, tissée TUNIC, SURGICAL, woven CASAQUE CHIRURGICALE.uu., avec manches longues; 300 Use as second pair for specific heavy duty jobs. HOSPITERA "GREENFIT PLUS" Nitra Tex EP Ansell Medical ® Basic (first) pair of gloves. 100 pce Small; 100 pce Medium; 100 pce Large) 50 Use as second pair for sensitive jobs (e.g. pulse taking). 100 1 per shift for each isolation worker, and members of the ambulance & burial teams. (= trousers of scrub suit) 100 1 per shift for each isolation worker, and members of the ambulance & burial teams. (= blouse of scrub suit) 28 HARTMANN ® XXL. SALOPETTE de PROTECTION; PROTECTIVE OVERALL 10 Mao collar welded overall. Topguard ®; Tyvek-Pro.Tech ® -- NON STERILE BANDAGE, COHESIVE, elastic, 10 cm x 3 m BANDE COHESIVE, élastique, 10 cm x 3 m TABLIER PROTECTION, plastique HEAVY DUTY; APRON PROTECTION, plastic HEAVY DUTY BOTTES, caoutchouc, (pair) BLANC; BOOTS, rubber, (pair) WHITE 2 DISPOSABLE GOWN with long sleeves 16 17 SDREBANC103 18 ELINAPRS1R- 19 20 ELINMASP1HF MASQUE DE PROTEC., RESP.(PCM2000 FLUIDSHIELD) haute filtra; MASK, PROTECTION, RESP.(PCM2000 FLUIDSHIELD) high filtration For securing fitting of wrist band of gown with edge of glove. 5 APRON SURGICAL, rubber 5 2 pairs size 39; and 3 pairs size 43 100 21 COIFFE CHIRURGICAL u.u. ; SURGICAL CAPS Disposable 50 Cagoule Ortopédique non tissé polypropylène souple et leger EVERCAP ® REF C12 ; Code 686408BD (Hospitera) 22 COIFFE avec masque a six lacets incorporés; CAP (HOOD) with 6 laces mask LUNETTES DE PROTECTION, plastique (GOGGLES), ; GOGGLES, PROTECTIVE, plastic SPRAY anti-Buée;(2 ounce spray); Anti-FOG spray (2 ounce spray) SAC, plastique, mortuaire, blanc, 150 microns, 220 cm ; BAG, body, plastic, white, 150 microns, 220 cm 50 Topguard ®; Tyvek-Pro.Tech ® -NON STERILE 23 24 25 26 27 28 29 30 31 SMSUBAGB2W- EBOLA BRIEFING MSF 2001 L002CLIG01E L002CLIG01F L014DRUG01F L014DRUG01E L003HEFB02F 32 L003HEFB02E 33 L003ZTF0002 CLINICAL GUIDELINES GUIDE CLINIQUE ET THERAPEUTIQUE MEDICAMENTS ESSENTIELS - Guide pratique d'utilisation ESSENTIAL DRUGS - Practical guidelines Controle de l'infection en cas de FIEVRE HEMORRAGIQUE VIRALE en milieu hospitalier africain, OMS/CDC 208 p Infection control of VIRAL HAEMORRAGIC FEVERS in Afr. health. WHO/CDC 198p PROCEDURE DE PRELEVEMENT DE SANG FR; 5 1 FLEXY® wraparound Goggles BS 2092,2 CDM = diving spray (Trident, 2 ounce spray, #LP80) Use anti-fog spray provided in same module of kit. Use to diminish fogging of goggles. 4 Use double if no coffin. 1 1 1 1 1 1 Briefing document & field use. MSF standard clinical guideline (English) MSF standard clinical guideline (French) MSF standard essential drugs guideline (French) MSF standard essential drugs guideline (English) Guidelines for Viral Haemorrhagic Fevers (French) 1 Guidelines for Viral Haemorrhagic Fevers (English) 1 MSF - Guidelines for sampling taking (French). 286 34 35 L003ZTF0002 L003ZTF004 PROCEDURES FOR BLOOD DRAWNING ENG. Standard Forms for Haemorrhagic Fev. (paper) Eng + fr.Set 1 2 36 L003ZTF004 Standard Forms for Haemorrhagic Fev. (disc) Eng + fr. 1 37 ASTABOOE2SH CAHIER, 210 x 297 mm, à spirale, quadr. 5 mm, rigide, 180p.; 1 38 ASTAPENM3BB 39 ASTAPENF1BS 40 PPACBAGP1B- MSF - Guidelines for sampling taking (English). Case and contact definitions (EHF); Case reporting form; Contact recording form; Contact tracing form; Steps for putting ON (& OFF) protective clothing); Clinical data form. Case and contact definitions (EHF); Case reporting form; Contact recording form; Contact tracing form; Steps for putting ON (& OFF) protective clothing); Clinical data form. EXER. BOOK, 210x297mm, spiral bind, 5mm sq, hard cover, 180p 41 MARQUEUR, noir, indélébile, géant, pointe carrée ; MARKER, black, permanent, large, square tip CRAYON FEUTRE, pointe fine, noir; PEN, FELT, black, sharp SAC, poubelle, plastic, 100 l, noir, 70 microns ; BAG, dustbin, plastic, 100 l, black, 70 microns PULVERISATEUR 1L Plastique SPRAYER 1L Plastic CUILLER A SOUPE, plastique, 15 grammes; PLASTIC TABLE SPOONS 15 gr plastic HYPOCHLORITE de CALCIUM (HTH) 70% granules 500 g embal. IATA; HTH 70% IATA PACKING SAVON, 200 g, barre; SOAP, 200 g, bar RUBAN ADHESIF, MSF, PVC (rouleau); TAPE, adhesive, MSF, PVC (roll) SCISEAUX DE LORENZ, courbes, 24 cm 40-13-24 SCISSORS, LORENZ, curved, 24 cm 40-13-24 1 3 20 3 42 CWATZTF0104 43 CWATYCAH7G5 44 DEXTSOAP1B2 45 PPACTAPE1M- 46 ESURSCIS24- 47 CSHETAPE2BF RUBAN DE BALISAGE, blanc/orange, fluorescent, rouleau 500 m ; TAPE, BOUNDARY marking, white/orange, fluorescent, roll 500m 1 Quick pre-fencing of risk zones or isolation unit. 48 KMEDMSAM1S- 2 For sampling on filter paper. 49 ELAEBSVC1P- 50 ELAEBSVV1H- 51 ELAEBSVV21N MODULE PRELEVEMENT SEROLOGIE, transport ; MODULE, SAMPLE, SEROLOGY, transport (système prél.sanguin) RECIPIENT PROTECTEUR ; (blood sampling system) CONTAINER, PROTECTION (s.prél.sang.) CORPS PORTE TUBE (Vacutainer) ; (blds. syst.) HOLDER for VACUUM TUBE (Vacutainer) (s.prél.sang) AIGUILLE, stérile, 21G (Vacutainer); (blds.syst.) NEEDLE, sterile, 21G (Vacutainer) SKIN-SNIP-BIOPSY-SET (MSF packed) composed of : (1 x POINCON A BIOPSIE USAGE 5mm UNIQUE--SKIN BIOPSY PUNCH 5mm disposable); (1 x SET ENLEVEMENT DE FIL UU; -- SUTURE REMOVAL KIT DISPOSABLE); (2 x RECIPIENT avec FORMOL (min 20 ml); -- VIAL WITH FORMALIN (min 20 ml)) (Liver puncture) Aiguille pour biopsie de tissue (Liver puncture Needle for tissue biopsy 52 53 54 (Liver puncture) RECIPIENT avec FORMOL (min 20 ml); (Liver puncture) VIAL WITH FORMALIN (min 20 ml). 5 5 For measuring chlorine (1 table spoon (cuiller à soupe) holds ~15 g HTH). IATA Packing Disinfection; Water treatment. 10 1 1 LORENZ Ciseaux à pansements, Courbés, 24 cm de long, MEDICOM INSTRUMENTE® ref. 40.13.24 10 For blood sampling. 15 For blood sampling. 10 For blood sampling. 3 Each set needs to be packed separately. For skin-snip biopsy. 1 Monoject biopsy needle 13G, 3 1/2" Kendall ® code 1100-247194 For liver biopsy (post-mortem) If required to take liver sample, only physicians experienced in biopsies should do this. 2 For liver biopsy (post-mortem) If required to take liver sample, only physicians experienced in biopsies 287 should do this. 55 SINSSYRD10- 56 ELAECONT6U- 57 58 59 ASTASTIC428 SERINGUE, u.u., Luer, 10 ml SYRINGE, disposable, Luer, 10 ml; POT A PRELEVEMENT, urine, plastique, non stérile, 60 ml CONTAINER, SAMPLE, urine, plastic, non-sterile, 60 ml; BOITE, emballage triple, transport Diagnostic Specimen; BOX, triple packing, transp. of Diagnostic Specimen. BOITE ISOTHER, emb. Triple, transp. Diagnostic Specimen; BOX ISOTHERM, triple pack., transp. of Diagnostic Specimen ETIQUETTE, AUTOCOLLANTE, A4, 28 unités 105x25 mm, pr fiches ; STICKER, ADHESIVE, A4, 28 units 105x21 mm, for stock card 5 5 For urine and stool samples. Respect cold chain for differential diagnosis (dysentery). 2 For transport of samples of unknown diagnostic. 2 For transport of samples of unknown diagnostic. 100 For identification of samples. 288 Annex 17.1 Assessment Kit – Locally Composed This is a rapid field assessment kit. It was used during the Uganda 2000 Ebola outbreak, to assess sub-outbreaks (Ebola confirmed). It can be used to set up a small isolation facility, and allows isolation and treatment of three patients for 2 days. Protective equipment calculations are based on 1 nurse, 1 cleaner and 1 guard in 3 shifts; 3 person burial & ambulance team performing 1 collection and 1 burial; 2 patient attendants; and 2 visitors. Quantities and items should be adjusted according to the needs of the field. Item No. Description 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 Protective Materials & Medical Supplies Disposable gloves: medium Disposable gloves: large Disposable gowns or overalls: Surgical gloves: sterile size 7.5 Household gloves: pairs Disposable head covers Disposable masks Plastic goggles Long heavy plastic or rubber apron Cotton blouse Cotton trousers Gum boots sizes 39, 40, 41, 42 Gum boot sizes 43, 44 Stethoscope Plastic bags for medications Iodine 200 ml Thermometer Sphygmomanometer Tourniquet IV placement unit 18G IV placement unit 22G Ringers lactate: l litre IV giving sets ORS sachets Amoxicillin caps 250 mg Ciprofloxacin 250 mg Chloroquine 150mg base Paracetamol 500 mg tabs Paracetamol 100 mg tabs Diazepam 5mg/ml in 2 ml vials Metoclopramide 10mg tab Needles 19G Syringe 2ml Syringe 5 ml Syringe 10 ml Tongue depressors 50% glucose: 50 ml Other Supplies: watsan, disinfection, etc. Quantity 200 200 50 100 20 100 100 20 20 6 6 4 each 4 each 1 50 1 3 1 1 10 10 12 12 50 50 40 50 50 50 5 25 10 10 10 10 10 4 289 Item No. Description Quantity 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 5 6 6 1 10 2 4 3 1 2 20 5 10 1 2 2 1 3 25 57 58 59 60 61 62 63 64 65 66 67 68 69 HTH 70% 1kg Buckets: 20 litres with lid - plastic Basin for hand washing, patient needs Rope ball Body bags Mattress covers Jerry cans, plastic 20 litres Jerry cans, 5 litres Plastic sheeting, roll Water containers 125 litres Plastic waste disposal bags Plastic tablespoons Soap, bars Sparadrap: 2.5 cm x 5 m 10 litre sprayer 1 litre sprayer Pool tester Paper towels rolls Disposable bed pads 60 x 60 cm Books & Stationery Essential drugs 1999 Clinical guidelines 1999 CDC VHF manual WHO VHF manual Instruction materials, 3 copies each form Donation forms Patient hospitalisation forms Case definition forms Surveillance case report forms Plastic envelopes for forms Hardcover registration books Pens Note Books 1 1 1 1 20 sets 10 10 20 5 30 3 10 5 290 Annex 17.2 Health Centre Kit This kit allows health workers temporarily to take in charge a suspect VHF case while awaiting transfer to the VHF treatment unit. This kit should be composed locally and distributed to Peripheral Health Care facilities during medical outreach. Before distribution, training has to be given, and health centre workers need to know and understand the safety protocols for working with suspect VHF cases. If this is not the case, it can be more dangerous to distribute this kit and give untrained health care workers a false sense of safety because of the protection equipment in it. Quantities and items should be adjusted according to the needs: size of health structures, number of consultations, etc. Item 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Description 20 litre bucket with cover Household bleach solution Disposable latex gloves, medium size Plastic apron Rubber boots Household gloves Disposable mask Goggles Head cover Single use gowns Plastic sheet - 2 x 2 meters for covering mattress Laundry soap bars Plastic garbage bags Plastic basin for hand washing after consultation Body bags Chlorine sprayer of 1 litre capacity Sponge Sharps box (or modified drug pot) Documentation Sheets Universal precautions Case definitions Preparation of chlorine solutions Sterilisation procedure Use of chlorine solutions in VHF Triage forms Information and sensitisation material Quantity Health Health Centre Post 2 2 15 btls 10 btls 500 200 2 2 2 pairs 2 pairs 2 pairs 2 pairs 20 10 2 2 4 4 4 4 5 2 10 5 10 10 1 1 2 2 1 1 5 2 2 1 1 1 1 1 1 400 500 1 1 1 1 1 200 300 291 Annex 17.3 Home Based Support and Risk Reduction Kit This is a household kit distributed to families taking care of patients under the Risk Reduction Programme. Depending on distances and ease of transport, one trained community-based public health technician can support 10 households. Item No. 1 2 3 4 5 6 7 8 9 10 Kit Content per Household Description Quantity 11 12 13 14 15 16 17 18 19 Plastic apron Goggles or face shield Single use overalls Shoe covers Household gloves Face masks Examination gloves Plastic sheeting (2m x 2m) Jerry can 10-15 litres (for 0.5% and 0,05% solutions) Pre-measured doses of HTH for preparation of 0.5% and 0.05% chlorine solutions in the jerry cans Plastic bottle 1 litre (prepare & store ORS solution) Bucket 10 litres with lid (waste collection) Plastic bowl 20 litres (dishes and clothes washing) Absorbent pads Sanitary pads (3/day x 5 days) Toilet paper Washing powder Soap Plastic rubbish bag 60 litres 1 1 pair 5 10 pairs 2 pairs 10 15 pairs 1 piece 2 5 of each dose 1 2 3 4 5 6 7 8 9 10 11 12 Kit Content Per Public Health Technician Sprayer 8l(for disinfection of household) HTH 70% Water container 100 litres Funnel Plastic apron Household gloves 15 ml measure (preparing chlorine solution) Plastic bottle 1 litre (prepare & store Cl solution) Plastic jug 1 litre Plastic rubbish bag 100 litres Thermometer Notepad and pen 1 2 3 4 5 Equipment For Supply And Supervision Of Programme Water tank 5m3 (fixed location or mobile on truck) 1 Sprayer 8 litre 2 Plastic bottles 1 litre 2 Household gloves 10 pairs Plastic apron 1 1 2 1 15 15 2 rolls 2 bags 1 piece 5 1 1 kg 2 1 1 5 pairs 1 2 1 20 1 1 Back to Table of Contents 292 Annex 18 Quality and Requirements for Protective Equipment When large quantities of protective equipment are ordered from Europe, supply problems may arise and particular items may not be available. In this situation, alternative products must be identified which meet the specific protective requirements for each item. The following is a brief overview of the key characteristics of the PPE. Protective gear needs to be TRULY PROTECTIVE and COMFORTABLE to wear without having to touch or adjust it under hot and humid tropical climate conditions. Gloves: Two pairs of gloves are worn in the high-risk zone and for high-risk activities; one pair of gloves is worn in the low-risk zone. High-risk examination gloves: first pair for everybody. Household gloves: second pair for heavy-duty activities (burial, ambulance teams, sprayer, etc). Surgical gloves: second pair for sensitive jobs (taking pulse, etc.). Requirements Long enough (cover half of the forearm). Fit closely and securely on wrist and forearm (narrow and long). Strong, flexible and durable. Allow the sensitivity required for certain activities (pulse taking). Disposable Overalls and Surgical Gowns: Waterproof / hydrophobic. Long enough (should reach top of feet, but not drag on the ground). Completely covering the front and back of the body. Long enough sleeves to reach wrists; with elasticised wristbands. Easily closed with secure fastenings. There must be no pockets. Three good types are: A. Mao collar, welded overall. Topguard ®; Tyvek-Pro Tech ® - NON-STERILE. B. HARTMANN ® FOLIODRESS E (“special” or “perfect”) C. KLINIDRAPE ® Art nr 863402 Both Hartmann and Klinidrape should be standard XL and XXL (50% stock of each). Shorter people can tear a strip off the bottom so it does not drag on the ground. Disposable masks: Maximum facial surface covered, and edges should seal well to the face. Masks should be wide enough to meet with head cover and the goggles. Simple and easy to put on and take off. Waterproof / hydrophobic. Has to be comfortable to wear without having to readjust or touch it. Must allow an easy through-flow of air, and should not be fatiguing to wear even when soaked with sweat and/or condensation. Preferably HEPA-filtration, minimum N95. No expiry valve. 293 Disposable Caps (head covers): Maximum covering (neck also). Hood style with shoulder covering. Waterproof / hydrophobic. Scrub suit: Easy to wear. Not too hot (light cotton). Without pockets. Boots: Preferably bright colour (white) for recognition and identification as “isolation boots”. Comfortable and non-slip. Reach top of calves. Aprons: Long enough to reach ankle. Strong and durable. Flexible and large enough to enclose body. Bright colour (white) for recognition, possibility to see dirt, and identification as “isolation aprons”. Disinfectable light tarpaulin or strong plastic. Goggles: Must be completely protective (side and top). Shielded air inlets. Anti blur (use also anti-fog spray in kit). Easy & comfortable to wear. Different types must be available to fit different face shapes. Garbage bags: Strong and leak proof. Easy closing. Body bags: Strong and easily closed. Waterproof: should not leak. Long enough zipper tabs. If too small, can be difficult to manipulate zipper when wearing two pairs of gloves. If long zipper tab are not available, attach small string to tab before starting burial procedure. Smooth zipper to avoid damaging glove. Sprayers: Corrosion free material. Durable construction. Easy to position on back, and to carry. Adjustable nozzles. Easy to clean. Back to Table of Contents 294 Annex 19 Glossary anorexia antibody antigen anuria arthralgia asthenia case definition contagion dysphagia dyspnoea dystocia eclampsia edema / oedema ELISA (enzyme-linkedimmunosorbent serologic assay epidemic epidemic curve epidemiological description episiotomy epistaxis haematemesis haemoptysis hypokalaemia hypovolaemia IgG IgM ileus immunohistochemistry invasive procedures isolation myalgia nosocomial infection oedema / edema orchitis outbreak palliative parotitis PCR (polymerase chain reaction) preeclampsia Loss of appetite for food. Type of protein in the blood that produces immunity against microorganisms or their toxins. A molecule or substance that is recognised by the immune system, which triggers an immune response, such as the release of antibodies. Absence of urine. Joint pain. Weakness, debility Criteria for deciding whether a person has a particular disease. Disease transmission by direct or indirect contact. Difficulty in swallowing, or inability to swallow. Shortness of breath, difficult or laboured breathing. Difficult delivery. Coma and convulsions during or immediately after pregnancy. (see preeclampsia below) An accumulation of an excessive amount of watery fluid in cells and tissues of the body A technique used to detect the presence of specific substances, such as enzymes, viruses, antibodies, or bacteria. Synonymous with “outbreak”. The occurrence of cases of an illness in a community or region, which is in excess of the number of cases normally expected for that disease in that area at that time. A histogram that shows the course of an outbreak by plotting the number of cases of a disease according to time of onset. A description of the characteristics of an outbreak taking account of age, sex, location, symptoms, treatment, case confirmation status, and clinical outcome of patients. Incision to enlarge vaginal opening during childbirth Nosebleed. Vomiting of blood. Coughing blood Potassium deficiency, usually indicative of a systemic potassium deficit. Lack of blood in the body; due to blood loss or dehydration. A type of antibody present in blood serum that can indicate a recent infection. IgG is most prevalent about 3 weeks after an infection begins. A type of antibody present in blood serum that is usually indicative of an acute infection. Obstruction of the bowel, not necessarily a mechanical obstruction. A type of assay whereby specific antigens are made visible by the use of fluorescent dye or enzyme markers. Procedures that require insertion of an instrument or device into the body through the skin or a body orifice. The segregation of an infected individual to prevent the spread of infection to others. Muscular pain or tenderness. An infection acquired by a patient at a hospital or other health structure. An accumulation of an excessive amount of watery fluid in cells and tissues of the body Inflammation of the testes. Synonymous with “epidemic”. Can be perceived as less sensational than "epidemic". “Outbreak” is sometimes used to refer to a localised event and “epidemic” to a more widespread occurrence. Treatment that provides symptomatic relief, but not a cure. Inflammation of the parotid glands, as in mumps. Laboratory method for amplifying DNA or RNA of an organism to aid identification. A condition of hypertension occurring in pregnancy, typically accompanied 295 quarantine reservoir sequelae tachypnoea triage uveitis vasoactive virulence zoonosis by oedema and proteinuria (excessive protein in the urine). The segregation or restriction of movement of individuals who may have been exposed to a disease, but show no signs or symptoms of the disease. Any person, animal, arthropod, plant, soil, or substance in which an infective agent normally lives and multiplies. Pathological condition(s) resulting from a disease. An abnormally rapid (usually shallow) respiratory rate; hyperventilation. A system of assessing and sorting patients according to the likelihood of a specific disease or the severity of their illness, to aid in referral to appropriate isolation options and treatment. Inflammation within the eyeball. Causing constriction or dilation of blood vessels. The measure of severity of a disease. An infectious disease that is transmissible from animals to humans. Back to Table of Contents 296 Annex 20 Bibliography Briefing: Ebola Outbreak Preparedness & Management, 1st version. Médecins Sans Frontières, 2001. Bushmeat Hunting, Deforestation, and Prediction of Zoonotic Disease Emergence. N. Wolfe, P. Daszak, A. Kilpatrick, D. Burke, Emerging Infectious Diseases. CDC, 2005. Communicable Disease Toolkit for Angola: Health Surveillance Forms. WHO, 2005. Compte Rendu du Séminaire de Formation des Formateurs et d’Analyse des Épidémies de Fièvres Hémorragiques à Virus Ebola en Afrique Centrale de 2001 à 2003. Ministère de la Santé et de la Population, République du Congo & Organisation Mondiale de la Santé, 2004. Control of Communicable Diseases Manual. D. Heymann, American Public Health Association, 2004. Cultural Contexts of Ebola in Northern Uganda. B. Hewlett & R. Amola, Emerging Infectious Diseases. CDC, 2003. Ebola Hemorrhagic Fever Transmission and Risk Factors of Contacts, Uganda. P. Francesconi, Emerging Infectious Diseases, 2003. Ecologic and Geographic Distribution of Filovirus Disease. A. Townsend Peterson, J. Bauer, J. Mills, Emerging Infectious Diseases. CDC, 2004. Epidemiologic Surveillance during Marburg Virus Outbreak; Experience from Uige, Angola, 2005. Evelyn Depoortere, Internal Report, Epicentre, 2005. Ethical Guidelines for Biomedical Research on Human Subjects. Indian Council of Medical Research, 2000. Fact Sheet - Isolation and Quarantine. Department of Health & Human Services, CDC, 2004. Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings. Presentation, Department of Health & Human Services, CDC, 2004. Guideline for Hand Hygiene in Health-Care Settings. Morbidity and Mortality Weekly Report, CDC, 2002. Health Care Waste Management in Low-income Countries. J. Van Den Noortgate, Médecins Sans Frontières, 2004. I Feel Good: During Mission and After. Médecins Sans Frontières, 2006. Infection Control for Viral Haemorrhagic Fevers in the African Health Care Setting. WHO-CDC, 1998. Infection Control in Precarious Situations. N. Isouard, MSF, 2005. Investigating Cause of Death during an Outbreak of Ebola Virus Haemorrhagic Fever: Draft Verbal Autopsy Instrument. Department of Communicable Disease Surveillance and Response, WHO, 2003. Management and Control of Viral Haemorrhagic Fevers and Other Highly Contagious Viral Pathogens. European Network for Diagnostics of Imported Viral Diseases, 2001. Public Health Engineering in Emergencies. Médecins Sans Frontières, 2005. Quarantine After An International Biological Weapons Attack: Building Cooperation, Achieving Consistency. Summary of Wilton Park Special Conference, Advanced Systems and Concepts Office (ASCO), Defence Threat Reduction Agency (DTRA), 2004. Risk Factors for Marburg Hemorrhagic Fever, Democratic Republic of the Congo. D. Bausch, Emerging Infectious Diseases, 2003. The Ethics of Quarantine. R. Upshur, Virtual Mentor Series, American Medical Association, 2003. Uige Marburg Project Final Report. MSF - OCBA, 2005. WHO Outbreak Communication Guidelines. WHO, 2005. WHO Recommended Guidelines for Epidemic Preparedness and Response: Ebola Haemorrhagic Fever (EHF). WHO, 1997. Back to Table of Contents 297
