VIRAL HEMORRHAGIC FEVERS (VHF)

Dr Mostafa Mahmoud MD Ph DConsultant Microbiologist

Labs amp Blood Banks Admin RiyadhHead of IPampC Dept Iman Hospital

Assist Prof of Medical Microbiology amp Immunology

What are VHFs

bull Initial nonspecific prodromal stagebull Feverbull Malaisebull Headachebull Myalgia arthralgia bullAbdominal pain bullNon-bloody diarrhea

bull Clinical multi-system illness associated with fever amp bleeding diathesis (tendencies) caused by several distinct families of viruses

bull Then Progresses to more severe symptoms amp death

bullHemorrhage (not all cases)bull Increased vascular permeabilitybull Hypotension and ShockbullMultiorgan failure

bull Many cause rapidly progressive illness amp high mortality rates

CAUSATIVE VIRAL GROUPS (4)

Viral group Representative viruses 1- Filoviruses Ebola V and Marburg V2- Flaviviruses (82 members)

-Yellow fever V ndashWest Nile V ndash Dengue Fever V

3- Bunyaviruses (Rift Valley fever virus (RVV) Crimean-Congo hemorrhagic fever (CCHF) virus and Hantavirus pulmonary syndrome (HPS)2- Arenavirus Lassa Fever VNew World Arena Viruses

What are VHFs

bull Initial nonspecific prodromal stagebull Feverbull Malaisebull Headachebull Myalgia arthralgia bullAbdominal pain bullNon-bloody diarrhea

bull Clinical multi-system illness associated with fever amp bleeding diathesis (tendencies) caused by several distinct families of viruses

bull Then Progresses to more severe symptoms amp death

bullHemorrhage (not all cases)bull Increased vascular permeabilitybull Hypotension and ShockbullMultiorgan failure

bull Many cause rapidly progressive illness amp high mortality rates

CAUSATIVE VIRAL GROUPS (4)

Viral group Representative viruses 1- Filoviruses Ebola V and Marburg V2- Flaviviruses (82 members)

-Yellow fever V ndashWest Nile V ndash Dengue Fever V

3- Bunyaviruses (Rift Valley fever virus (RVV) Crimean-Congo hemorrhagic fever (CCHF) virus and Hantavirus pulmonary syndrome (HPS)2- Arenavirus Lassa Fever VNew World Arena Viruses

bull Then Progresses to more severe symptoms amp death

bullHemorrhage (not all cases)bull Increased vascular permeabilitybull Hypotension and ShockbullMultiorgan failure

bull Many cause rapidly progressive illness amp high mortality rates

CAUSATIVE VIRAL GROUPS (4)

Viral group Representative viruses 1- Filoviruses Ebola V and Marburg V2- Flaviviruses (82 members)

-Yellow fever V ndashWest Nile V ndash Dengue Fever V

3- Bunyaviruses (Rift Valley fever virus (RVV) Crimean-Congo hemorrhagic fever (CCHF) virus and Hantavirus pulmonary syndrome (HPS)2- Arenavirus Lassa Fever VNew World Arena Viruses

CAUSATIVE VIRAL GROUPS (4)

Viral group Representative viruses 1- Filoviruses Ebola V and Marburg V2- Flaviviruses (82 members)

-Yellow fever V ndashWest Nile V ndash Dengue Fever V

3- Bunyaviruses (Rift Valley fever virus (RVV) Crimean-Congo hemorrhagic fever (CCHF) virus and Hantavirus pulmonary syndrome (HPS)2- Arenavirus Lassa Fever VNew World Arena Viruses

Flaviviruses

VIROLOGY OF VHF (FEATURES OF THE VIRUSES)

bull All are single-stranded RNAbull All are enveloped (transmission by foods or drinks)bull Infectious during viremia stagebull Low infectivity dose (1-10 viruses can cause infections)bullGeographically restricted to areas where host livesbullHumans are not the natural reservoir but accidentally infected when comes in contact with infected hostsbullHuman outbreaks are sporadic and irregular

bullWhen human is infected can infect another human bullNo established treatment (with few exceptions) bull The best treatment is control of infection

bull Role in bioterrorism (biological weapons due to high morbidity and mortality and due to aerosol transmission of most of them except dengue fever virus)

EPIDEMIOLOGY OF HFV DISEASE TRANSMISSION

- HFVs are zoonosis Animal hosts (Rodents) and arthropod vectors are main reservoirs

A Natural infection of humans (mode of transmission)1 Bite of infected arthropod (ticks or mosquitos) 2 Aerosol from infected rodent excreta3 Direct contact with infected animalscarcasses or

fomites

B- Human to Human amp Nosocomial Transmissionbull Possible for most HFVs (except )- Most person-to-person spread due to direct contact with infected blood amp body fluids (Hospital acquires infections HAIs- Mucous membrane contact- Aerosolized (airborne in Ebola Lassa Juniacuten amp may be yellow fever)- Semen - vomitus - Sweatbull Incubation period ranging from 2 to 21 days for all of them

PATHOGENESIS

bull The target organ is the vascular bed (hemorrhage)bull The replication of virus is intracellularlybull Cytokine release leads to shock and hypotensionbull Affects platelet functions and numbers (thrombocytopenia)bull Affects bone marrow and clotting factors

CASE-FATALITY (MORTALITY) RATE Virus Mortality rate Filoviruses Around 90 for Ebola virus (the

highest)Flaviviruses

05

Arenaviruses

15-30Causes of death1- Hemorrhagic diathesis (several body sites amp orifices) 2- Shock3- Multi-organ failure

DIFFERENTIAL DIAGNOSISInfectious conditions Non-infectious

conditionsInfluenza Viral hepatitisStaphylococcal or gram ndash sepsisMeningococcemia Salmonellosis and shigellosis LeptospirosisMalariaRickettsial diseaseMeasles Smallpox ndash hemorrhagicToxic ShockSepticemic PlagueTrypanosomiasis

DIC ITP TTP HUS Acute leukemia VasculitisCollagen-vascular diseases

I- FILOVIRUSES A- EBOLA VIRAL DISEASE (EVD)

B- MARBURG VIRUS

1- Category A bioweapon (bioterrorism) agents (CDC 1999)2- Potential to cause widespread illness deathbull Ease of dissemination or person-to-person transmissionbull First appeared in Zaire and Sudan simultaneously in 1976bullOutbreak in 2013 in guinea then to Liberia Sierra Leone and lately Nigeria

bull Case fatality rate (CFR) approaches 90

bull The virus was transmitted to humans

from wild animals

bull Fruit Bats are considered as the natural host for the virus bullOther reservoirs rodents and plant virus

EBOLA VIRUS DISEASE TRANSMISSION 1- By direct human-to-human contact with the blood or other body secretions (saliva breast milk tears stool skin or semen) of infected persons or even Dead bodies (NB Lab staff at risk)2- Transmission through semen may occur up to 7 weeks after clinical recovery (Sexual transmission)3- Indirect contact transmission via environment contaminated with such infected secretions4- By handling ill or dead infected chimpanzees or other infected animals

5- Health care workers (HCWs) have frequently been infected while attending patients (direct contact body fluids Needle sticks aerosols)

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

VIROLOGY OF VHF (FEATURES OF THE VIRUSES)

bull All are single-stranded RNAbull All are enveloped (transmission by foods or drinks)bull Infectious during viremia stagebull Low infectivity dose (1-10 viruses can cause infections)bullGeographically restricted to areas where host livesbullHumans are not the natural reservoir but accidentally infected when comes in contact with infected hostsbullHuman outbreaks are sporadic and irregular

bullWhen human is infected can infect another human bullNo established treatment (with few exceptions) bull The best treatment is control of infection

bull Role in bioterrorism (biological weapons due to high morbidity and mortality and due to aerosol transmission of most of them except dengue fever virus)

EPIDEMIOLOGY OF HFV DISEASE TRANSMISSION

- HFVs are zoonosis Animal hosts (Rodents) and arthropod vectors are main reservoirs

A Natural infection of humans (mode of transmission)1 Bite of infected arthropod (ticks or mosquitos) 2 Aerosol from infected rodent excreta3 Direct contact with infected animalscarcasses or

fomites

B- Human to Human amp Nosocomial Transmissionbull Possible for most HFVs (except )- Most person-to-person spread due to direct contact with infected blood amp body fluids (Hospital acquires infections HAIs- Mucous membrane contact- Aerosolized (airborne in Ebola Lassa Juniacuten amp may be yellow fever)- Semen - vomitus - Sweatbull Incubation period ranging from 2 to 21 days for all of them

PATHOGENESIS

bull The target organ is the vascular bed (hemorrhage)bull The replication of virus is intracellularlybull Cytokine release leads to shock and hypotensionbull Affects platelet functions and numbers (thrombocytopenia)bull Affects bone marrow and clotting factors

CASE-FATALITY (MORTALITY) RATE Virus Mortality rate Filoviruses Around 90 for Ebola virus (the

highest)Flaviviruses

05

Arenaviruses

15-30Causes of death1- Hemorrhagic diathesis (several body sites amp orifices) 2- Shock3- Multi-organ failure

DIFFERENTIAL DIAGNOSISInfectious conditions Non-infectious

conditionsInfluenza Viral hepatitisStaphylococcal or gram ndash sepsisMeningococcemia Salmonellosis and shigellosis LeptospirosisMalariaRickettsial diseaseMeasles Smallpox ndash hemorrhagicToxic ShockSepticemic PlagueTrypanosomiasis

DIC ITP TTP HUS Acute leukemia VasculitisCollagen-vascular diseases

I- FILOVIRUSES A- EBOLA VIRAL DISEASE (EVD)

B- MARBURG VIRUS

1- Category A bioweapon (bioterrorism) agents (CDC 1999)2- Potential to cause widespread illness deathbull Ease of dissemination or person-to-person transmissionbull First appeared in Zaire and Sudan simultaneously in 1976bullOutbreak in 2013 in guinea then to Liberia Sierra Leone and lately Nigeria

bull Case fatality rate (CFR) approaches 90

bull The virus was transmitted to humans

from wild animals

bull Fruit Bats are considered as the natural host for the virus bullOther reservoirs rodents and plant virus

EBOLA VIRUS DISEASE TRANSMISSION 1- By direct human-to-human contact with the blood or other body secretions (saliva breast milk tears stool skin or semen) of infected persons or even Dead bodies (NB Lab staff at risk)2- Transmission through semen may occur up to 7 weeks after clinical recovery (Sexual transmission)3- Indirect contact transmission via environment contaminated with such infected secretions4- By handling ill or dead infected chimpanzees or other infected animals

5- Health care workers (HCWs) have frequently been infected while attending patients (direct contact body fluids Needle sticks aerosols)

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

bullWhen human is infected can infect another human bullNo established treatment (with few exceptions) bull The best treatment is control of infection

bull Role in bioterrorism (biological weapons due to high morbidity and mortality and due to aerosol transmission of most of them except dengue fever virus)

EPIDEMIOLOGY OF HFV DISEASE TRANSMISSION

- HFVs are zoonosis Animal hosts (Rodents) and arthropod vectors are main reservoirs

A Natural infection of humans (mode of transmission)1 Bite of infected arthropod (ticks or mosquitos) 2 Aerosol from infected rodent excreta3 Direct contact with infected animalscarcasses or

fomites

B- Human to Human amp Nosocomial Transmissionbull Possible for most HFVs (except )- Most person-to-person spread due to direct contact with infected blood amp body fluids (Hospital acquires infections HAIs- Mucous membrane contact- Aerosolized (airborne in Ebola Lassa Juniacuten amp may be yellow fever)- Semen - vomitus - Sweatbull Incubation period ranging from 2 to 21 days for all of them

PATHOGENESIS

bull The target organ is the vascular bed (hemorrhage)bull The replication of virus is intracellularlybull Cytokine release leads to shock and hypotensionbull Affects platelet functions and numbers (thrombocytopenia)bull Affects bone marrow and clotting factors

CASE-FATALITY (MORTALITY) RATE Virus Mortality rate Filoviruses Around 90 for Ebola virus (the

highest)Flaviviruses

05

Arenaviruses

15-30Causes of death1- Hemorrhagic diathesis (several body sites amp orifices) 2- Shock3- Multi-organ failure

DIFFERENTIAL DIAGNOSISInfectious conditions Non-infectious

conditionsInfluenza Viral hepatitisStaphylococcal or gram ndash sepsisMeningococcemia Salmonellosis and shigellosis LeptospirosisMalariaRickettsial diseaseMeasles Smallpox ndash hemorrhagicToxic ShockSepticemic PlagueTrypanosomiasis

DIC ITP TTP HUS Acute leukemia VasculitisCollagen-vascular diseases

I- FILOVIRUSES A- EBOLA VIRAL DISEASE (EVD)

B- MARBURG VIRUS

1- Category A bioweapon (bioterrorism) agents (CDC 1999)2- Potential to cause widespread illness deathbull Ease of dissemination or person-to-person transmissionbull First appeared in Zaire and Sudan simultaneously in 1976bullOutbreak in 2013 in guinea then to Liberia Sierra Leone and lately Nigeria

bull Case fatality rate (CFR) approaches 90

bull The virus was transmitted to humans

from wild animals

bull Fruit Bats are considered as the natural host for the virus bullOther reservoirs rodents and plant virus

EBOLA VIRUS DISEASE TRANSMISSION 1- By direct human-to-human contact with the blood or other body secretions (saliva breast milk tears stool skin or semen) of infected persons or even Dead bodies (NB Lab staff at risk)2- Transmission through semen may occur up to 7 weeks after clinical recovery (Sexual transmission)3- Indirect contact transmission via environment contaminated with such infected secretions4- By handling ill or dead infected chimpanzees or other infected animals

5- Health care workers (HCWs) have frequently been infected while attending patients (direct contact body fluids Needle sticks aerosols)

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

EPIDEMIOLOGY OF HFV DISEASE TRANSMISSION

- HFVs are zoonosis Animal hosts (Rodents) and arthropod vectors are main reservoirs

A Natural infection of humans (mode of transmission)1 Bite of infected arthropod (ticks or mosquitos) 2 Aerosol from infected rodent excreta3 Direct contact with infected animalscarcasses or

fomites

B- Human to Human amp Nosocomial Transmissionbull Possible for most HFVs (except )- Most person-to-person spread due to direct contact with infected blood amp body fluids (Hospital acquires infections HAIs- Mucous membrane contact- Aerosolized (airborne in Ebola Lassa Juniacuten amp may be yellow fever)- Semen - vomitus - Sweatbull Incubation period ranging from 2 to 21 days for all of them

PATHOGENESIS

bull The target organ is the vascular bed (hemorrhage)bull The replication of virus is intracellularlybull Cytokine release leads to shock and hypotensionbull Affects platelet functions and numbers (thrombocytopenia)bull Affects bone marrow and clotting factors

CASE-FATALITY (MORTALITY) RATE Virus Mortality rate Filoviruses Around 90 for Ebola virus (the

highest)Flaviviruses

05

Arenaviruses

15-30Causes of death1- Hemorrhagic diathesis (several body sites amp orifices) 2- Shock3- Multi-organ failure

DIFFERENTIAL DIAGNOSISInfectious conditions Non-infectious

conditionsInfluenza Viral hepatitisStaphylococcal or gram ndash sepsisMeningococcemia Salmonellosis and shigellosis LeptospirosisMalariaRickettsial diseaseMeasles Smallpox ndash hemorrhagicToxic ShockSepticemic PlagueTrypanosomiasis

DIC ITP TTP HUS Acute leukemia VasculitisCollagen-vascular diseases

I- FILOVIRUSES A- EBOLA VIRAL DISEASE (EVD)

B- MARBURG VIRUS

1- Category A bioweapon (bioterrorism) agents (CDC 1999)2- Potential to cause widespread illness deathbull Ease of dissemination or person-to-person transmissionbull First appeared in Zaire and Sudan simultaneously in 1976bullOutbreak in 2013 in guinea then to Liberia Sierra Leone and lately Nigeria

bull Case fatality rate (CFR) approaches 90

bull The virus was transmitted to humans

from wild animals

bull Fruit Bats are considered as the natural host for the virus bullOther reservoirs rodents and plant virus

EBOLA VIRUS DISEASE TRANSMISSION 1- By direct human-to-human contact with the blood or other body secretions (saliva breast milk tears stool skin or semen) of infected persons or even Dead bodies (NB Lab staff at risk)2- Transmission through semen may occur up to 7 weeks after clinical recovery (Sexual transmission)3- Indirect contact transmission via environment contaminated with such infected secretions4- By handling ill or dead infected chimpanzees or other infected animals

5- Health care workers (HCWs) have frequently been infected while attending patients (direct contact body fluids Needle sticks aerosols)

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

B- Human to Human amp Nosocomial Transmissionbull Possible for most HFVs (except )- Most person-to-person spread due to direct contact with infected blood amp body fluids (Hospital acquires infections HAIs- Mucous membrane contact- Aerosolized (airborne in Ebola Lassa Juniacuten amp may be yellow fever)- Semen - vomitus - Sweatbull Incubation period ranging from 2 to 21 days for all of them

PATHOGENESIS

bull The target organ is the vascular bed (hemorrhage)bull The replication of virus is intracellularlybull Cytokine release leads to shock and hypotensionbull Affects platelet functions and numbers (thrombocytopenia)bull Affects bone marrow and clotting factors

CASE-FATALITY (MORTALITY) RATE Virus Mortality rate Filoviruses Around 90 for Ebola virus (the

highest)Flaviviruses

05

Arenaviruses

15-30Causes of death1- Hemorrhagic diathesis (several body sites amp orifices) 2- Shock3- Multi-organ failure

DIFFERENTIAL DIAGNOSISInfectious conditions Non-infectious

conditionsInfluenza Viral hepatitisStaphylococcal or gram ndash sepsisMeningococcemia Salmonellosis and shigellosis LeptospirosisMalariaRickettsial diseaseMeasles Smallpox ndash hemorrhagicToxic ShockSepticemic PlagueTrypanosomiasis

DIC ITP TTP HUS Acute leukemia VasculitisCollagen-vascular diseases

I- FILOVIRUSES A- EBOLA VIRAL DISEASE (EVD)

B- MARBURG VIRUS

1- Category A bioweapon (bioterrorism) agents (CDC 1999)2- Potential to cause widespread illness deathbull Ease of dissemination or person-to-person transmissionbull First appeared in Zaire and Sudan simultaneously in 1976bullOutbreak in 2013 in guinea then to Liberia Sierra Leone and lately Nigeria

bull Case fatality rate (CFR) approaches 90

bull The virus was transmitted to humans

from wild animals

bull Fruit Bats are considered as the natural host for the virus bullOther reservoirs rodents and plant virus

EBOLA VIRUS DISEASE TRANSMISSION 1- By direct human-to-human contact with the blood or other body secretions (saliva breast milk tears stool skin or semen) of infected persons or even Dead bodies (NB Lab staff at risk)2- Transmission through semen may occur up to 7 weeks after clinical recovery (Sexual transmission)3- Indirect contact transmission via environment contaminated with such infected secretions4- By handling ill or dead infected chimpanzees or other infected animals

5- Health care workers (HCWs) have frequently been infected while attending patients (direct contact body fluids Needle sticks aerosols)

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

PATHOGENESIS

bull The target organ is the vascular bed (hemorrhage)bull The replication of virus is intracellularlybull Cytokine release leads to shock and hypotensionbull Affects platelet functions and numbers (thrombocytopenia)bull Affects bone marrow and clotting factors

CASE-FATALITY (MORTALITY) RATE Virus Mortality rate Filoviruses Around 90 for Ebola virus (the

highest)Flaviviruses

05

Arenaviruses

15-30Causes of death1- Hemorrhagic diathesis (several body sites amp orifices) 2- Shock3- Multi-organ failure

DIFFERENTIAL DIAGNOSISInfectious conditions Non-infectious

conditionsInfluenza Viral hepatitisStaphylococcal or gram ndash sepsisMeningococcemia Salmonellosis and shigellosis LeptospirosisMalariaRickettsial diseaseMeasles Smallpox ndash hemorrhagicToxic ShockSepticemic PlagueTrypanosomiasis

DIC ITP TTP HUS Acute leukemia VasculitisCollagen-vascular diseases

I- FILOVIRUSES A- EBOLA VIRAL DISEASE (EVD)

B- MARBURG VIRUS

1- Category A bioweapon (bioterrorism) agents (CDC 1999)2- Potential to cause widespread illness deathbull Ease of dissemination or person-to-person transmissionbull First appeared in Zaire and Sudan simultaneously in 1976bullOutbreak in 2013 in guinea then to Liberia Sierra Leone and lately Nigeria

bull Case fatality rate (CFR) approaches 90

bull The virus was transmitted to humans

from wild animals

bull Fruit Bats are considered as the natural host for the virus bullOther reservoirs rodents and plant virus

EBOLA VIRUS DISEASE TRANSMISSION 1- By direct human-to-human contact with the blood or other body secretions (saliva breast milk tears stool skin or semen) of infected persons or even Dead bodies (NB Lab staff at risk)2- Transmission through semen may occur up to 7 weeks after clinical recovery (Sexual transmission)3- Indirect contact transmission via environment contaminated with such infected secretions4- By handling ill or dead infected chimpanzees or other infected animals

5- Health care workers (HCWs) have frequently been infected while attending patients (direct contact body fluids Needle sticks aerosols)

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

CASE-FATALITY (MORTALITY) RATE Virus Mortality rate Filoviruses Around 90 for Ebola virus (the

highest)Flaviviruses

05

Arenaviruses

15-30Causes of death1- Hemorrhagic diathesis (several body sites amp orifices) 2- Shock3- Multi-organ failure

DIFFERENTIAL DIAGNOSISInfectious conditions Non-infectious

conditionsInfluenza Viral hepatitisStaphylococcal or gram ndash sepsisMeningococcemia Salmonellosis and shigellosis LeptospirosisMalariaRickettsial diseaseMeasles Smallpox ndash hemorrhagicToxic ShockSepticemic PlagueTrypanosomiasis

DIC ITP TTP HUS Acute leukemia VasculitisCollagen-vascular diseases

I- FILOVIRUSES A- EBOLA VIRAL DISEASE (EVD)

B- MARBURG VIRUS

1- Category A bioweapon (bioterrorism) agents (CDC 1999)2- Potential to cause widespread illness deathbull Ease of dissemination or person-to-person transmissionbull First appeared in Zaire and Sudan simultaneously in 1976bullOutbreak in 2013 in guinea then to Liberia Sierra Leone and lately Nigeria

bull Case fatality rate (CFR) approaches 90

bull The virus was transmitted to humans

from wild animals

bull Fruit Bats are considered as the natural host for the virus bullOther reservoirs rodents and plant virus

EBOLA VIRUS DISEASE TRANSMISSION 1- By direct human-to-human contact with the blood or other body secretions (saliva breast milk tears stool skin or semen) of infected persons or even Dead bodies (NB Lab staff at risk)2- Transmission through semen may occur up to 7 weeks after clinical recovery (Sexual transmission)3- Indirect contact transmission via environment contaminated with such infected secretions4- By handling ill or dead infected chimpanzees or other infected animals

5- Health care workers (HCWs) have frequently been infected while attending patients (direct contact body fluids Needle sticks aerosols)

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

DIFFERENTIAL DIAGNOSISInfectious conditions Non-infectious

conditionsInfluenza Viral hepatitisStaphylococcal or gram ndash sepsisMeningococcemia Salmonellosis and shigellosis LeptospirosisMalariaRickettsial diseaseMeasles Smallpox ndash hemorrhagicToxic ShockSepticemic PlagueTrypanosomiasis

DIC ITP TTP HUS Acute leukemia VasculitisCollagen-vascular diseases

I- FILOVIRUSES A- EBOLA VIRAL DISEASE (EVD)

B- MARBURG VIRUS

1- Category A bioweapon (bioterrorism) agents (CDC 1999)2- Potential to cause widespread illness deathbull Ease of dissemination or person-to-person transmissionbull First appeared in Zaire and Sudan simultaneously in 1976bullOutbreak in 2013 in guinea then to Liberia Sierra Leone and lately Nigeria

bull Case fatality rate (CFR) approaches 90

bull The virus was transmitted to humans

from wild animals

bull Fruit Bats are considered as the natural host for the virus bullOther reservoirs rodents and plant virus

EBOLA VIRUS DISEASE TRANSMISSION 1- By direct human-to-human contact with the blood or other body secretions (saliva breast milk tears stool skin or semen) of infected persons or even Dead bodies (NB Lab staff at risk)2- Transmission through semen may occur up to 7 weeks after clinical recovery (Sexual transmission)3- Indirect contact transmission via environment contaminated with such infected secretions4- By handling ill or dead infected chimpanzees or other infected animals

5- Health care workers (HCWs) have frequently been infected while attending patients (direct contact body fluids Needle sticks aerosols)

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

I- FILOVIRUSES A- EBOLA VIRAL DISEASE (EVD)

B- MARBURG VIRUS

1- Category A bioweapon (bioterrorism) agents (CDC 1999)2- Potential to cause widespread illness deathbull Ease of dissemination or person-to-person transmissionbull First appeared in Zaire and Sudan simultaneously in 1976bullOutbreak in 2013 in guinea then to Liberia Sierra Leone and lately Nigeria

bull Case fatality rate (CFR) approaches 90

bull The virus was transmitted to humans

from wild animals

bull Fruit Bats are considered as the natural host for the virus bullOther reservoirs rodents and plant virus

EBOLA VIRUS DISEASE TRANSMISSION 1- By direct human-to-human contact with the blood or other body secretions (saliva breast milk tears stool skin or semen) of infected persons or even Dead bodies (NB Lab staff at risk)2- Transmission through semen may occur up to 7 weeks after clinical recovery (Sexual transmission)3- Indirect contact transmission via environment contaminated with such infected secretions4- By handling ill or dead infected chimpanzees or other infected animals

5- Health care workers (HCWs) have frequently been infected while attending patients (direct contact body fluids Needle sticks aerosols)

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

bull Case fatality rate (CFR) approaches 90

bull The virus was transmitted to humans

from wild animals

bull Fruit Bats are considered as the natural host for the virus bullOther reservoirs rodents and plant virus

EBOLA VIRUS DISEASE TRANSMISSION 1- By direct human-to-human contact with the blood or other body secretions (saliva breast milk tears stool skin or semen) of infected persons or even Dead bodies (NB Lab staff at risk)2- Transmission through semen may occur up to 7 weeks after clinical recovery (Sexual transmission)3- Indirect contact transmission via environment contaminated with such infected secretions4- By handling ill or dead infected chimpanzees or other infected animals

5- Health care workers (HCWs) have frequently been infected while attending patients (direct contact body fluids Needle sticks aerosols)

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

EBOLA VIRUS DISEASE TRANSMISSION 1- By direct human-to-human contact with the blood or other body secretions (saliva breast milk tears stool skin or semen) of infected persons or even Dead bodies (NB Lab staff at risk)2- Transmission through semen may occur up to 7 weeks after clinical recovery (Sexual transmission)3- Indirect contact transmission via environment contaminated with such infected secretions4- By handling ill or dead infected chimpanzees or other infected animals

5- Health care workers (HCWs) have frequently been infected while attending patients (direct contact body fluids Needle sticks aerosols)

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

5- Health care workers (HCWs) have frequently been infected while attending patients (direct contact body fluids Needle sticks aerosols)

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

bull Health care workers (HCWs) have critical situations

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Filoviruses Ebola amp Marburg - Cause severe HF that similar to fulminant septic shock- Mortality Rate Ebola 50-90

Marburg 25-30- Incubation period 2-21 days for Ebola (Mean 8 -10)

3-10 days for Marburg

96 days (mean) from symptom onset to death

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

VIROLOGY Filovirus family includes Ebola and Marburg virusesSingle stranded-RNA (ssRNA) enveloped virusEbola virus contains 5 strains with different phylogenic tree (Zaire Sudan Ivory Coast Reston amp New 5th Guinea strain High mutational potentialsRapidly replicating within 8 HsU or 6-shape virus

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

What is wrong here

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

II- Flaviviruses

A- Yellow FeverB- Dengue Fever

C- Omsk HFD- Kyasanur Forest Disease

NB Flavus in Latin means yellow

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Mode of transmission- Yellow Fever ndash Aedes mosquito (A aegypti A africanus A simpsoni A furcifer A luteocephalus and A albopictus (Asian tiger mosquito)- Dengue Fever ndash mosquito (Aedes aegypti)- Omsk HFKyasanur FD Tick bite No reported cases of person to-person transmission

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Yellow Fever cycles

3 cycles for yellow feverJungleUrbanintermediate

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Flavivirus

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

A- Yellow FeverIncubation period short - 3-6 days CP1- Initial symptoms Fever chills severe HA back pain muscle aches nausea fatigue Most symptomatic patients develop only this stage however in 15 of symptomatic patients severe form will develop after short period of symptom remission (Toxic shock) 2- Toxic phase - fever returns with initial symptoms PLUS

Coagulopathy amp hemorrhage - hematemesis (black vomit) Jaundice Hypotension shock metabolic acidosis

arrhythmias Confusion seizures and coma can occur

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

NB The majority of persons infected with yellow fever virus have no illness or only mild illness - Fagetrsquos sign ndash relative bradycardia with fever- Mortality rate 5-10 (20-50 in epidemics and hospitalized pts)- NB 90 of cases occur in Africa 10 in South

America Vaccine is available (Atiqa PHC amp Airport) and indicated to travels to endemic area in Africa or South America- live-attenuated vaccine single dose - To gt 9 months travelers or living in endemic areas - Immunity in 1 week in 95 of people - Protection for 30-35 years- No specific treatment available

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

90 of yellow fever cases occur in Africa

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

10 of yellow fever cases occur in S America

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

- Described as ldquobreakbone feverrdquo by BenjaminRush in 1789

- Endemic throughout Americas Asia amp Africa - Vector - Aedes aegypti amp Aedes albopictus- Virus replicates in mosquitos - Very Rare by blood transfusion organs transplant amp Vertical transmission)- Incubation period 3-14 days- The Most prevalent mosquito-borne viral disease in the

world- 13 of world populations are exposed (400 million cases yearly)

B- Dengue Fever

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

- gt 100 countries have endemic dengue transmission - In USA Dengue - 104 of post-travel systemic febrile illness for travelers returning from endemic areas- No vaccine available (in 2015 new one is used

successfully by Sanofi Pasteur for people in endemic areas)

- No specific treatment

- In KSA it is present in Mecca and Jeddah

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Four Dengue Virus Serotypes (DEN 123 and 4)- All can cause severe amp fatal infection- Infection by one serotype gives No cross immunity

to other types but life long immunity to the same type however more predisposition to DHFDSS if infected by another serotype

- 2o immunopathological mechanism triggered by sequential infections with different dengue viral serotypes

- Complicated pathogenesis ndash partially attributable to Ab-dependent enhancement

- Humans are the main reservoir but monkeys may be

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

4 Clinical Manifestations of disease1- Undifferentiated fever2- Classic Dengue Fever3- Dengue Hemorrhagic Fever4- Dengue Shock Syndrome

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

2- Classic Dengue Fever

- Acute febrile illness - Severe Hemorrhage mainly retro-ocular - Myalgia amp arthralgia ndash often severe (breakbone fever)- Nausea amp vomiting gt 50 diarrhea (30) - Rash (50) (of variable appearances maculopapular petechial or erythematous

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

3- Dengue Hemorrhagic Fever (DHF) - Most serious form of dengue infection - WHO estimates 500000 cases year - Mortality asymp 10 high as 50

- WHO 4 diagnostic criteria (Fever (2-7 days) ndash Hemorrhagic manifestations ndash Low platelet counts (lt 100000 ml) ndash evidence of leaky capillaries)

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

4- Dengue Shock Syndrome (DSS)

4 WHO criteria for DHF AND Evidence of circulatory failure orshock - Rapid weak pulse narrow pulse pressure (lt 20 mm Hg) - Hypotension for age - Cold clammy skin AMS (Altered Mental Status)

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Epidemic year

Total cases DHF DSS Deaths

1993 1st case in Jeddah1994 (DEN-2)

469 23 2 2

2006 (DEN-1)

1269 27 2 6

2008 (DEN-3)

775 9 4 4

2011 23762013 4411

httpappswhointirisbitstream106654418819789241547871_engpdf

httpwwwncbinlmnihgovpmcarticlesPMC4057576

Dengue Fever in KSA

3 serotypes present (1 2 amp 3) Jeddah amp Makkah are affected due to pilgrims Aedes aegypti was detected also in Al-Maddinah

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

III- BunyavirusesA- Rift Valley Fever

B- HantavirusC- Crimean Congo HF

Viral hosts arthropod vectors amp rodents Mosquitoes ndash Rift Valley Fever Ticks ndash Crimean Congo Fever Rodents ndash Hantaan Virus All can be acquired by - Exposure to infected animals or their carcasses

- Contact with blood amp bodily secretions of infected persons - By aerosol

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

A- Rift Valley Fever- Mosquito-borne disease affects primarily sheep amp goats also cattle buffalos and camels- Most human infections are unapparent- Self limited febrile illness first reported in Kenyarsquos Rift

Valley in the early 1910s- Rare severe forms (Ocular retina

Meningoencephalitis or Hemorrhagic fever form) - 1 develops typical VHF- Short incubation 3-6 days- Mortality (variable) but less than 1

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Humans acquire infection by- Bite of infected mosquito (several species- vertical trans for yrs)- Contact with infected animal tissues- Aerosolization of virus from infected animal carcasses (Lab Staff)- Ingestion of contaminated raw animal milk(No reported cases of human-to-human transmission- still theoretical risk to HCWs)- Standard precautions are enough- Vaccination of animals but not during epidemics- Inactivated human vaccine is not licensed for

use

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

KSA Outbreak - Saudi Arabia Jizan amp Asir (from 26 August 2000 through 22 September 2001) 886 infected 87 dead (137)- The first time infection to be reported out of Africa- Vision loss 10683- Hemorrhagic manifestations were in 35494- CNS and liver affection occurs httpwwwkauedusaFiles140Researches50678_20846pdf

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Rift Valley fever Distribution

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

IV- Arenavirus

A- Lassa FeverB- New World Arena

Viruses

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

- Arenaviruses - rodent borne HFVs mainly rats and mice - Severe VHF in Africa amp S America- One case in North America - Incubation period 3-19 days2 Types Old World amp New World

i- Old World ndash Africa amp Europe - Lassa Fever - Lymphocytic Choriomeningitis (LCM)

ii- New World - Americas- South American HFVs - Junin (Argentine HF)- Machupo (Bolivian HF) - Whitewater Arroyho (North America)-Sabia virus (Brazilian HF)

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Mode of transmission

- Inhaled aerosols of rodent urinefeces- Ingestion of food or water contaminated with rodent excreta- Direct contact of rodent excreta with abraded skin mucous membranes- Contact with contaminated fomites- Contact with rodent blood- Sexual transmission is likely in Lassa virus (3 months in

semen)

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Person to person transmission does occur however - Direct contact with blood urine pharyngeal secretions amp other body fluids of patients (HCWs)- Airborne transmission possible (HCWs)- Sexual transmission likely (Lassa fever virus detected in semen up to 3 months after acute infection)

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

DIAGNOSIS MANAGEMENT AND CONTROL OF VHF

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Diagnosis of VHF amp HFVsCase Definition VHFs ndash Ebola Marburg New World Arenaviruses Old World Arenaviruses and CCHF (CDC 2011)Patient must have One or more of the following

- Fever ge 40 oC

- No predisposing factors for hemorrhagic manifestations -AND no established alternative diagnosis

-Severe headache -Muscle pain-Erythematous maculopapular rash on the trunk with fine desquamation 3ndash4 days after rash onset- Vomiting -Diarrhea- Abdominal pain -Thrombocytopenia - Bleeding not related to injury- Pharyngitis (arenavirus only)- Retrosternal chest pain (arenavirus only)- Proteinuria (arenavirus only)

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Important History within 21 days of 1 Patient from or travel to endemic areas1048708Even if nonspecific S+S 1048708Comprehensive travel history critical2 History of tick mosquito bites3 Contact with mice or their excreta4 History of contact with patient with above risk factors amp VHF symptoms5 Contact with sick animals or carcasses in endemic areas

6- In the event of Bioterrorist attack event

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

1- Non-specific Lab Abnormalities

- Leukopenia-Anemia- Hemoconcentration- Thrombocytopenia- Elevated LFTs-Azotemia

2- Coagulation abnormalities

- Prolonged bleeding time PT PTT- Increased FDP (fibrin degradation

products)- Decreased Fibrinogen- DIC

3-Urine analysis Hematuria proteinuria oliguria

A- Non specific Lab Abnormalities in HFV Infection

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Test Notes Lab level

Antigen detection by PCR

- The Early rapid diagnostic test

2nd or 3rd BSL

Antigen detection by ELISA test

Rapid diagnostic test 2nd or 3rd BSL

IgM detection by ELISA

Late diagnosis after 10 days of onset of infection

2nd or 3rd BSL

Viral isolation Takes 3-days to completeMostly in research less in clinical diagnosis

4th BSL

B- Specific Lab diagnostic test in HFV Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Isolation (Airborne in Lassa Ebola Marburg)

No FDA approved antiviral agents

Aspirin amp NSAIDs

Fluid amp electrolyte balance

Ribavirin used in Arenaviruses and in Bunyaviruses

Anticoagulant therapies

Supplemental O2 amp Mechanical Ventilation

Ribavirin not active against (F) Filoviruses of Flaviviruses

Steroids are of no benefit

Treatment of HFVs Infection

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Supportive (Main treatment)

Specific antiviral treatment

Contraindicated

Circulatory amp BP supportEarly vasopressorsBlood products (Platelets Clotting factor amp FFPPain controlSecondary infections common -aggressive treatment with antimicrobials

Treatment of HFV Infection (Continue)

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Immunization and infection control in HFVs

1- Passive immunizationbull Immune plasma in Arenavirusis (Junin and Machupo)bullWhole blood from Ebloa survivors

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

2- Active Immunization for HFVs

1- Live-attenuated vaccine available and effective for yellow fever virus2- Inactivated virus for dengue fever is under trial with good success 3- Vaccines for Junin (Argentine) virus under trial4- Also Rift Valley virus vaccine is under trial

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

INFECTION CONTROL amp HFVS Infection-control Guidelines- Stick to the standard precautions is the gold standard - Report suspected cases immediately to Infection control officer MOH which notify the CDC- Isolation of all suspected cases (Negative pressure Room or single room)- Strict hand washing (HH)- Double gloving- Use of impermeable gowns

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

- N-95 masks or powered air-purifying respirators (PAPR)- Negative pressure isolation with 6-12 air exchanges hour - Leg amp shoe covering - Face shields amp goggles

- All contacts of patients diagnosed with VHF including hospital personnel amp lab workers should be placed under medical surveillance for signs of VHF infection for 21 days

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

NOTIFICATION PROCESS IN VHF (MOH-KSA)bull The following notifications are mandatory if suspected cases of VHF are admitted

1 The Admitting Consultant notifies thea Infectious Diseases Consultantb Nurse in charge of Emergency Department and

Ward where patient is to be admitted2 The Infectious Diseases Consultant notifies the

a Chairman of the Infection Control Committee who will then notify the

i Medical Director ii Executive on Dutyiii Infection Control Practitioner

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

3 The Nurse in charge of ER notifies thea Nursing Supervisor or Duty Administratorb ICU Head Nurse if the patient is to be admitted to

the ICU4 The Chairman of Infection Control Committee notifies the

a Hospital Directorb Laboratory and Radiology Departmentsc Employee Health Department

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

5 The Infection Control Practitioner notifies thea Housekeeping Managerb CSSD Managerc Ministry of Healthd Utilities and Maintenance for ventilation

modification in patient rooms6 The Nursing Supervisor notifies the

a Director of Nursingb Nurse manager to consult on staffingc Materials department for equipment for strict

isolation

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

INFECTION CONTROL AND LAB TESTINGbull All HFVs are highly infectious in lab settingbull May be transmitted to lab personnel by small particle aerosolsbull Notify lab immediately if VHF suspectedbull All specimens should be

- Clearly identified - Double bagged- Hand carried to lab- Do NOT transport specimens in pneumatic tube

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

CDC Recommendations for personal protection during specimen

collectionFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns Additional PPE may be required in certain situations

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Specimen Handling for Routine Laboratory Testing (suspected Ebola

case but not for Ebola Diagnosis) (CDC)Routine laboratory testing includes traditional chemistry hematology and other laboratory testing used to support and treat patients The following precautions are required to deal with specimens suspected to contain Ebola virus for routine laboratoryFull face shield or goggles masks to cover all of nose and mouth gloves fluid resistant or impermeable gowns AND use of a certified class II Biosafety cabinet or plexiglass splash guard as well as manufacturer-installed safety features for instruments

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

POST-EXPOSURE PROPHYLAXIS amp MANAGEMENT

bullNo vaccine or antiviral agentsbull Percutaneous or mucocutaneous exposures Immediately wash affected skin with soap and water flush eyesbullHigh Risk Exposures amp Close Contacts

- Place under medical surveillance- Record temps 2 times day Report any temp ge 38

oC-Report any SS of VHF- Initiate Ribavirin if SS of VHF develop (Arenavirus or

Bunyavirus only)

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

bull Prophylactic antiviral therapy (including Ribaviran) NOT recommended for persons exposed to HFVs in the absence of clinical illness

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Postmortem Practices in VHF - PPE for mortuary staffs during contact with cadavers as they are implicated in Ebola transmission - Recommendations in a VHF outbreak - Prompt burial or cremation - Minimal handling of corpses (washing only in hospital) - NO embalming - Surgery or post-mortem exams (Autopsy) only when absolutely necessary

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Environmental Decontamination and housekeeping for HFVs- Wear PPE when entering patient room (mask gown amp

Gloves)- Designated cleaning equipment (mops paints wet

vacuum)- Double bag all linens and wash in bleach- Disinfect surfaces with 1100 bleach solution (Cholorox)- HFVs are not environmentally stable- Use of only yellow bag for garbage in isolation rooms

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Mosquitos controlInsecticides meshes mosquito-eating fishes etc

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

HFVS AS BIOWEAPONS

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

Character Availability

- High Morbidity +Mortality - Low infective dose - Potential for person-person transmission- Highly infectious by aerosol dissemination- Vaccine unavailable or limited supply - Potential to cause public amp HCWs anxiety fear

radicradicradic+- radicradicradic

- Availability of pathogen or toxin- Feasibility of large scale production- Environmental stability- Prior research amp development as weapon

+- radic+- radicradicradic

Character of microorganism for being biological

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

SELECTED EPIDEMIOLOGIC CHARACTERISTICS OF ILLNESS CAUSED BY CATEGORY A BIOLOGIC

AGENTSDisease Incubation period

Duration of illness

Case fatality rates (CFR)

Inhalational anthrax

1-6 days 3 - 5 days Untreated 100Treated 45

Botulism 6 hrs-10 days 24 -72 hrs Outbreak-associated first patient 25Subsequent patients 4

Tularemia 1 - 21 days 2 weeks Untreated 33Treated lt4

Pneumonic plague 2-3 days 1- 6 days Untreated 40-70Treated 5

Smallpox 7-17 days 4 weeks Overall 20-50Viral hemorrhagic fevers

2-21 days 7-16 days Overall 53-88

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

WEAPONIZED HFVVirus Country of weaponization Ebola Virus Russia and former Soviet

UnionJapan (attempted)

Marburg virus Russia and former Soviet UnionLassa virus Russia and former Soviet New World Arenaviridae (Junin and Machupo)

Russia and former Soviet

Rift Valley FeverYellow Fever North Korea (reportedly)Omsk hemorrhagic feverKyasanur Forest Disease

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

As HCWs Everyone is responsible for infection control he must break this chain at his point(s) of concern

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

REFERENCES bull HTTPHEALTHMOGOVLIVINGHEALTHCONDISEASESCOMMUNICABLECOMMU

NICABLEDISEASECDMANUALPDFHEMORRHAGICPDFbull CDCrsquoS NATIONAL NOTIFIABLE DISEASES SURVEILLANCE SYSTEM (NNDSS) AND

CASE DEFINITIONS HTTPWWWNCDCGOVNNDSS bull HTTPWWWCDCGOVYELLOWFEVERSYMPTOMSINDEXHTMLbull HTTPAPPSWHOINTIRISBITSTREAM106654418819789241547871_ENGP

DFbull HTTPWWWWHOINTMEDIACENTREFACTSHEETSFS207ENbull GCC INFECTION PREVENTION AND CONTROL MANUAL 2ND EDITION 2013 copy

2013 NATIONAL GUARD HEALTH AFFAIRS GULF COOPERATION COUNCIL ndash CENTRE FOR INFECTION CONTROL RIYADH 22490 KINGDOM OF SAUDI ARABIA

THANK YOU

• Viral hemorrhagic fevers (vhf)
• What are VHFs
• Slide 3
• Causative Viral groups (4)
• Slide 5
• Slide 6
• Virology of vhf (features of the viruses)
• Slide 8
• Epidemiology of HFV Disease Transmission
• Slide 10
• pathogenesis
• Case-fatality (mortality) rate
• Differential Diagnosis
• I- filoviruses A- ebola viral disease (EVD) B- Marburg virus
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Virology
• Slide 21
• Slide 22
• Slide 23
• Slide 24
• Slide 25
• Slide 26
• Slide 27
• Slide 28
• Slide 29
• Slide 30
• Slide 31
• Slide 32
• Slide 33
• Slide 34
• Slide 35
• Slide 36
• Slide 37
• Slide 38
• Slide 39
• Slide 40
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• Slide 48
• Slide 49
• Slide 50
• Slide 51
• Slide 52
• Slide 53
• Diagnosis management and control of vhf
• Slide 55
• Slide 56
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Immunization and infection control in HFVs 1- Passive immunizat
• Slide 62
• Infection Control amp HFVs
• - N-95 masks or powered air-purifying respirators (PAPR) - Neg
• Notification Process in VHF (MOH-KSA)
• Slide 66
• Slide 67
• Infection Control and Lab Testing
• CDC Recommendations for personal protection during specimen col
• Specimen Handling for Routine Laboratory Testing (suspected Ebo
• Post-Exposure Prophylaxis amp Management
• Slide 72
• Slide 73
• Slide 74
• Slide 75
• Slide 76
• Slide 77
• Slide 78
• HFVs as Bioweapons
• Slide 80
• Selected epidemiologic characteristics of illness caused by Cat
• Weaponized HFv
• Slide 83
• References
• Thank you