The Toronto Hospital Viral Hemorrhagic Fever (VHF) Contingency Plan
Introduction
Recently an outbreak of Ebola virus infection occurred in Zaire during which there were 296 known cases resulting in 237 deaths. The majority of those who died were health care personnel and family members who cared for infected individuals. Cases of Ebola were identified in 6 separate hospital locations including the site of the first case in Kikwit.
Ebola is one of 4 known dangerous and highly contagious viruses which produce hemorrhagic fever in Africa. Lassa, Marburg, and Congo-Crimean Hemorrhagic fever viruses are all found in various parts of Africa. These infections are characterized by non-specific symptoms such as fever, headache, sore throat, muscle pains, cough, gastrointestinal upset and rash.
Hemorrhagic phenomena which often triggers clinicians to consider the diagnosis of a VHF do not develop until the second week of illness. The case fatality rates range from 15 to 80% depending on the infecting virus. They are spread primarily by blood and body fluid exposure, sexual activity and very close contact with an infected person. These viruses do not usually spread through casual contact or aerosols (small droplets spread beyond 1 metre). The Disease Control Service, Ontario Ministry of Health has designated The Toronto Hospital as a referral site for patients suspected or diagnosed with a viral hemorrhagic fever.
Contingency Plan
There is a Canadian contingency plan for viral hemorrhagic fevers which is available from the Laboratory Centres for Disease Control in Ottawa. The hospital contingency plan is modeled after the Canadian contingency plan.
1)Triage
A system has been set up through Public Health officials regarding the transport of individuals returning from Africa with undiagnosed febrile illnesses and in all likelihood they would be transported to tertiary care facilities. Patients who come through the emergency room who come from Africa, who have febrile illnesses should be triaged as soon as possible.
Case Management
There are 3 major areas of concern with regards to the management of these patients and they include patient isolation, the conduct and processing of laboratory tests and treatment. Patients should be isolated in single rooms with an adjoining anteroom which have demonstrated capacity for uni-directional air flow.
Currently at The Toronto Hospital, according to recent internal reports, the only functioning rooms are at the Toronto Western site and include rooms 138/140 and 146/148 on floor 3-6 and rooms 142 and 148 on floors 8 and 9 in the Fell Pavilion at the Western Division. In addition the 2 rooms in the critical care unit at the Western Division could be used. Strict barrier nursing techniques should be enforced with use of gloves, gowns, masks, shoe covers and disposable coverings.
Suitable disinfectant solutions including a 0.5% sodium hypochlorite (1:10 bleach) should be available. Members of the Infection Control Unit and Tropical Disease Unit will be available for consultation for details regarding the isolation of these patients.
Laboratory staff processing specimens from patients with suspected viral hemorrhagic fevers should take the same personal precautions as patient care staff. Tests should be performed in biosafety cabinets with every effort made to avoid creating any aerosolization. Specimens should be inactivated before automated equipment is used. Details regarding these procedures are available from members of the Tropical Disease or Infection Control Units. With regards to the treatment of the patient, experts in Tropical Diseases or Infectious Diseases should be consulted as to the use of specific antiviral agents.
Guest Editors
TROPICAL DISEASE UNIT
Dr. Kevin Kain 340-3535
Dr. Jay Keystone 340-3671
References:
Mitchell SW, McCormick JB. Physicochemical inactivation of Lassa, Ebola, and Marburg viruses and effect on clinical laboratory analyses. Am J Clin Microbiol Sept. 1984;20(3):486-9.
Elliott LH, McCormick JB, Johnson KM. Inactivation of Lassa, Marburg, and Ebola viruses by gamma irradiation. Am J Clin Microbiol Oct. 1982;16(4):704-8.
Laboratory Centre for Disease Control. Canadian contingency plan for viral hemorrhagic fevers. Laboratory Centre for Disease Control, Health Protection Branch, Department of National Health & Welfare, Ottawa. 1995 (in press).
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