Transcript
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
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
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
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- Virology
- Slide 21
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- Diagnosis management and control of vhf
- Slide 55
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- 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
- 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
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
- 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
- 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
- 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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