2015

NATIONAL GUIDELINES FOR

RECOGNITION & MANAGEMENT OF
VIRAL HAEMORRHAGIC FEVERS


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 Table Of Contents
Preface i
Acknowledgements ii
1. Introduction 1
2. Referral Of Viral Haemorrhagic Fever Patients 2
3. Background To The Viral Haemorrhagic Fevers 3
3.1 Rodent-associated viruses 3
3.1.1 Lassa Fever 3
3.1.2 Lujo virus 4
3.1.3 Hantaviruses 4
3.2 Arthropod-borne viruses (‘arboviruses’ or ‘insect-transmitted’ viruses) 5
3.2.1 Crimean-Congo haemorrhagic fever (CCHF or Congo fever) 6
3.2.2 Rift Valley Fever (RVF) 7
3.2.3 Chikungunya, Yellow fever and Dengue viruses 8
3.2.3.1 Chikungunya (CHIK) 8
3.2.3.2 Yellow fever 9
3.2.3.3 Dengue 9
3.3 Viruses believed to be associated with bats 9
3.3.1 Clincal features of Marburg and Ebola fevers 10
4. Diagnosis 12
4.1 Clinical diagnosis of VHF 12
4.2 Differential diagnosis of suspected VHF 15
4.2.1 Procedure to follow when VHF is suspected 15
4.2.2 Diseases commonly confused with VHF 15
4.2.3 Interpretation of clinical pathology results for differentiating VHFs
from other diseases 16
4.3 Laboratory verification of VHF 17
4.3.1 Source and nature of specimens 18
4.3.2 Packaging of specimens for transfer to NICD 19
4.3.3 Laboratory tests 20
4.3.4 Interpretation of results 20
5. Immediate Action To Be Taken After Clinical Diagnosis Of VHF 27
6. Management Of VHF Patients 29
6.1 Medical management of VHF patients 29
6.1.1 Antiviral therapy 29
6.1.2 Immune plasma therapy 30
6.1.3 Supportive treatment 31
6.2 Clinical pathology monitoring of VHF patients 33
6.3 Isolation precautions (formerly known as barrier-nursing procedures) 34
6.4 Disinfectants and decontamination 41
6.5 Disposal of corpses 45
7. Notification And Control Of Outbreaks Of VHF 46
7.1 Transfer of VHF patients 46
7.1.1 Arranging transfer of VHF patients 46
7.1.2 Non-ambulance transport of low risk VHF patients 47
7.1.3 Transport of VHF patients by ambulance 47
7.1.4 Importation of VHF patients and transportation by air 50
7.1.5 Imporation of VHF patients into South Africa by land and sea 52
7.2 Notification of cases of VHF 53
7.3 Public health respone to VHF outbreaks 54
7.3.1 Immediate responsibilities of Provincial CDCs during outbreaks of CHF 54
7.3.2 Tracing of contacts 56
7.3.3 Observation of contacts 58
7.4 Communication with the media 59
7.5 Long-term responsibilities of Provincial CDCs include 60
7.6 Requirements for a VHF referral centre 60
8. Key References 65
9. Appendix 1: Frequently asked questions on Crimean-Congo Haemorrhagic Fever 66

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 Preface

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 Acknowledgements

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 1. Introduction

Many infections, and even non-infectious diseases, can cause fever and a haemorrhagic state. It is important
to distinguish these conditions from viral haemorrhagic fevers (VHFs) caused by the so‑called formidable
or Class 4 viruses. The VHFs have in common a propensity for person-to-person spread and high mortality
rates, which necessitate that special infection control measures (isolation precautions) should be instituted
when managing suspected or confirmed cases of the diseases, and work with the viruses is permitted only
in biosafety level 4 (BSL4) laboratories. However, not all of the viruses associated with VHFs are uniformly
lethal or spread readily between humans: some less pathogenic viruses are placed in Class 4 in countries
from which they are absent in order to exercise control over their possible introduction.

Many parts of the world have endemic VHFs, and modern travel has made it possible for introduced cases to
occur virtually anywhere. The most common VHF in Southern Africa is caused by the tick-borne
Crimean-Congo haemorrhagic fever (CCHF or Congo fever) virus, and approximately 5-20 cases of the
disease are diagnosed in South Africa each year. Rift Valley fever, a zoonotic disease of sheep and cattle,
also occurs in our region, but human infections are generally seen in the context of major outbreaks of
disease in livestock which occur at irregular intervals of many years when exceptionally heavy rains favour
breeding of the mosquito transmitters of the virus, and human‑to‑human transmission has not been recorded.
The most recent large outbreak in South Africa was in 2010. In addition, the growing tendency for severely
ill patients from countries in tropical Africa to seek medical attention in South Africa is leading to increased
risk that cases of Lassa, Marburg and Ebola haemorrhagic fevers may be imported inadvertently. Fatal
nosocomial infections have occurred in South African hospitals in the past, and to avoid further tragedies
health care workers should maintain high standards of infection control and biosafety awareness at all times,
and all patient care facilities should institute contingency plans for dealing with VHF patients.

The present document, an updated version of guidelines first prepared in 1985, is intended as a guide to the
recognition and management of suspected and confirmed cases, and prevention of nosocomial spread, of the
indigenous African viral haemorrhagic fevers. The recommendations are not binding except where reference
is made to legislation, statutory regulations, or agreed protocol for dealings between separate organizations
and institutions, each of which should draft and implement protocols adapted to their own needs.

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 2. Referral Of Viral Haemorrhagic Fever Patients

After it was recognized in the 1980s that Congo fever is indigenous in South Africa, it was arranged that at least
one provincial hospital within each province should be designated as a referral centre for the management of
VHF patients, but circumstances have changed:
• It can no longer be assumed that VHF patients can automatically be referred to
designated provincial hospitals.
• All private hospitals, and public tertiary and regional hospitals should be adequately
resourced and prepared to handle VHF patients.
• All other public hospitals must have access to public referral hospitals that are
adequately resourced.

It is the responsibility of provincial Department of Health and Hospital Services, including the Coordinators of
Communicable Disease Control, to formulate and implement provincial policy with regard to referral of VHF
patients, including the designation of specific referral hospitals (see section 7).

Previous versions of the present document contained a list of designated referral hospitals with contact
details of persons with whom to liaise in order to arrange referral of VHF patients. Unfortunately this type
of information is subject to abrupt changes, and hence the management of each hospital (specifically
infection control officers) should establish for themselves what policy applies in their own province
or sub region with respect to referral of VHF patients, and keep up-to-date contact details for the
nearest designated VHF referral centre. Do not be caught unprepared.

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 3. Background To The Viral Haemorrhagic Fevers

Viruses associated with haemorrhagic fevers (Table 3.1), fall into three groups with respect to their reservoir
hosts and primary means of transmission, namely, rodent-associated viruses, arthropod-borne viruses, and
viruses thought to be associated with bats.

3.1 Rodent-associated viruses

The arenaviruses and hantaviruses cause chronic kidney infection in myomorph rodents (rats and mice) with
excretion of virus in the urine, and humans become infected from contaminated food or household items, but
there may also be occupational or recreational exposure to rodent excreta.

3.1.1 Lassa fever

Lassa fever is caused by an arenavirus that is confined to West Africa (Nigeria, Sierra Leone, Guinea
and Liberia are particularly affected). Related viruses that occur in rodents elsewhere in Africa were not
known to be pathogenic until the recent discovery of Lujo virus in southern Africa. Lassa fever infection is
generally associated with a comparatively mild disease with fever and a death rate of 1-2% among cases in
the community at large, but some patients develop haemorrhagic disease and deaths rates may approach
20% among hospitalised patients, or exceed 40% in nosocomial outbreaks. Person-to-person spread of
infection, which occurs in the home and hospital, appears to require overt contact with infected tissues and
body fluids. A physician from Nigeria who was evacuated for treatment in South Africa in 2007 proved to be
suffering from fatal Lassa fever, but fortunately there were no secondary infections.

Clinical features of Lassa fever

The incubation period is usually 7-10 days (range 3-21 days). Over 80% of infections are asymptomatic
or mild, but in the rest there is insidious onset of fever, chills, malaise, headache, generalized myalgia
and prostration. Within 2-3 days patients develop sore throat, vomiting, abdominal or chest (retrosternal)
pains, cough, hypotension and bradycardia. There is characteristic pharyngeal and tonsillar inflammation
with vesicular or ulcerative lesions and whitish or yellowish exudate. Conjuctivae are injected, and there is
lymphadenopathy, muscle tenderness, pulmonary rales, and sometimes maculopapular rash. From day 5
patients may progress to severe sustained fever and toxaemia with haemorrhages (epistaxis, haematemesis,
melaena), puffiness of the face and neck, serous effusions (hydrothorax), disorders of the central nervous
system and shock. The acute illness has a duration of 1-3 weeks. Deafness occurs in 25% of patients with
some recovery in 1-3 months, and there may be loss of hair and an unsteady gait during convalescence.

Clinical pathology of Lassa fever

Early leucopenia may be followed by leucocytosis. Proteinuria is common. Abnormalities in platelet counts,
prothrombin and clotting time are not marked, but there may be pronounced increases in serum levels of
aspartate and alanine transaminases, lactic dehydrogenase and creatine kinase. Viraemia lasts about a
week from the time of onset of disease but excretion of virus in urine may extend over 3-10 weeks.

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3.1.2 Lujo virus

In September - October 2008, there was a nosocomial outbreak of infection with a new arenavirus, Lujo
virus, in Johannesburg, involving 5 patients, 4 of whom died, with a clinical course similar to severe Lassa
fever. The first patient was transferred from Zambia to South Africa for medical management and the source
of her infection remains undetermined, although rodents are suspected. Three cases involved secondary
spread of infection from the first patient, and there was one tertiary infection. The secondary and tertiary
infections all occurred before isolation precautions were implemented. Several arenaviruses cause
hemorrhagic fevers in South America.

Clinical features of Lujo virus

Incubation period of 9-13 days; a prodomal illness characterized by fever, headache and myalgia, followed
by diarrhoea and pharyngitis and a morbiliform rash on the face and trunk reported in three cases on day
6-8 of illness. Facial swelling occurred in three patients with marked pharyngeal ulceration reported in one
patient. There appeared to be an initial clinical improvement after hospital admission in three patients,
followed by sudden, rapid deterioration in all patients who died. Bleeding was not a prominent feature. One
patient had a petechial rash and another had oozing of blood from venipuncture sites. One patient was
treated with intravenous ribavirin and survived.

Clinical pathology of Lujo virus

At the time of admission all patients had thrombocytopenia (range: 42-104 x 109/L). Liver transaminases
(AST and ALT) were raised in all five patients during the course of their illness.

3.1.3 Hantaviruses

Several hantaviruses are associated with a group of diseases in Europe and Asia which are known collectively
as haemorrhagic fever with renal syndrome (HFRS) (with fatality rates of <1-35%), while another group of
hantaviruses is associated with the hantavirus pulmonary syndrome (HPS) (fatality rates ≥50%) in North
and South America. Hantaviruses have been poorly studied in Africa, and there is as yet little evidence that
they occur here, except possibly for Seoul virus, thought to have been widely disseminated to sea ports with
ship-borne rats and occurring in urban settings.

Clinical features of Haemorrhagic Fever with Renal Syndrome (HFRS)

There are 4 clinical forms of the disease, varying in severity (<1-35% fatal) from nephropathia epidemica
associated with Puumala virus in Scandinavia, through mild or rat-borne HFRS associated with Seoul virus
infection which has been widely disseminated with ship-borne rats, to Far Eastern HFRS associated with
Hantaan virus in Asia (also known as Korean haemorrhagic fever), and so-called Balkan HFRS associated
with Dobrava virus. The incubation period is 2-3 weeks. Severe disease has five well-marked phases but
these overlap and are obscured in mild disease. An initial febrile phase of 3-7 days is marked by high fever,

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 chills, malaise, myalgia, anorexia, dizziness, headache and ocular pain, abdominal and back pain with
tenderness in the renal area (peritoneal and retroperitoneal oedema), followed by characteristic flushing
of the face neck and chest, with injection of the eyes, palate and pharynx which develops into a fine
petechial rash and conjunctival haemorrhage. There is marked proteinuria. A hypotensive phase follows
abruptly and lasts hours to 2 days, with tachycardia and classical shock: narrowed blood pressure, cold
and clammy skin, dulled senses and confusion; one third of fatal patients enter irreversible shock at this
stage. Proteinuria continues and there is mild haematuria, raised haematocrit level, leukemoid reaction
and thrombocytopenia. Onset of an oliguric phase of 3-4 days is marked by increasing blood urea and
creatinine levels. Blood pressure begins to normalize but hypertension can result from the hypovolaemic
state. There may be severe nausea and vomiting, and bleeding tendencies increase: epistaxis, conjunctival
haemorrhage, cerebral and gastro-intestinal haemorrhage and extensive purpura. There is hyperkalaemia,
hyponatraemia and hypocalcaemia. There may be central nervous symptoms and pulmonary oedema, with
50% of fatalities occurring in this phase. A diuretic phase may last days to weeks, with diuresis of up to 3-6
litres per day, and marks the start of recovery. The convalescent phase lasts 2-3 months with progressive
recovery of glomerular filtration rate.

Clinical features of Hantavirus Pulmonary Syndrome (HPS)

Persons who develop HPS are often healthy young adults, but may be of any age and either sex. The
incubation period is 2-3 weeks and onset is marked by sudden development of fever, headache, severe
myalgia and a cough, which may be productive in some instances. Gastrointestinal manifestations in some
patients include abdominal pain, nausea, vomiting and diarrhoea. After 3-6 days of illness there is progressive
tachypnoea, tachycardia and hypotension preceding the onset of acute respiratory distress with pulmonary
oedema. Patients are generally hospitalized at this stage, but some die before they can be admitted. On
admission patients may have proteinuria, leucocytosis with neutrophilia plus increased myeloid precursors
and atypical lymphocytes, haemoconcentration, and thrombocytopenia, and increased prothrombin and
partial-thromboplastin times, although there is no rash and very seldom a tendency towards overt or internal
bleeding. Within two days of being admitted to hospital most patients develop diffuse bilateral interstitial and
alveolar pulmonary infiltration and pleural effusions demonstrable on radiographs, with hypoxaemia, which
necessitates intubation, mechanical ventilation and oxygen supplementation. Sometimes there is renal
insufficiency and increased serum creatine kinase levels (evidence of skeletal muscle inflammation). Death
generally occurs 6-8 days after the onset of illness, often within 48 hours of admission to hospital, but can
range from 2 days after the observed onset of illness to more than two weeks. Fatality rates often exceed
40%, and incurable shock and myocardial dysfunction may contribute to the high mortality. Autopsies reveal
non-cardiogenic pulmonary oedema and serous pleural effusions, with scant lymphoid infiltration of the
lung tissue. Some survivors manifested transient diuresis, but otherwise they make an uneventful recovery
without sequelae.

3.2 Arthropod-borne viruses (‘arboviruses’ or ‘insect-transmitted’ viruses)

Several haemorrhagic fevers are caused by arboviruses. These are diverse viruses, which have in common
the fact that they are transmitted by blood-sucking arthropods (mosquitoes, midges, sand flies and ticks),

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with various wild and domestic animals serving as reservoir hosts (infected animals which serve as sources
of virus for infecting the arthropod vectors). Only a few arboviruses cause haemorrhagic disease.

3.2.1 Crimean-Congo haemorrhagic fever (CCHF or Congo fever)

Congo fever is the most frequently observed haemorrhagic fever in South Africa. It is caused by a tick-
borne virus, which occurs widely in Africa, Eastern Europe and Asia, within the distribution range of its main
vectors, ticks of the genus Hyalomma. These are known as bont-legged ticks in South Africa on account of
the distinctive brown and white bands on their legs. The disease is seen most frequently in the Northern
Cape, Free State and North West Provinces where the drier climate favours the bont-legged ticks, but
cases may occur anywhere in the country: patients infected in the Free State have become ill in KwaZulu-
Natal, and abattoir workers have developed the disease within the cities of Cape Town and Johannesburg.
The disease has an approximately 30% fatality rate and humans acquire infection from tick bite or from
contact of broken skin with fresh infected blood and tissues of livestock (sheep, cattle, ostriches), which
themselves undergo benign infection. Meat, which has been bled out and hung to mature according to
proper slaughterhouse procedures, is not infectious, and cooking destroys the virus. About 5-20 cases of
the disease are diagnosed in South Africa each year, and two South Africans are known to have acquired
infection during visits to Namibia and Tanzania. In addition, a patient from the DRC with unrecognised
CCHF was treated in South Africa; the diagnosis was only established after his death but fortunately there
were no secondary infections. Infection can occur in hospitals where medical staff comes into contact with
the blood of patients (needle sticks) or blood-tinged body fluids; there have been three such incidents
in South Africa involving 6 nurses, a surgeon and a laboratory technologist, with 3 fatalities. There is no
vaccine. A document on answers to frequently asked queations about the disease, compiled for people
involved in livestock industry is included as Appendix 1.

Clinical features of Congo fever

The incubation period commonly ranges from 1-3 days after tick bite, to 5-6 days after contact with infected
blood or other tissues, but may occasionally be longer. People are not always aware of being bitten by ticks
(look for ticks or bite marks, including on the scalp and between toes), but infection can also be acquired
from merely squashing ticks between the fingers. In contrast to the necrotic eschars that occur at the site
of the bites in tick bite fever (rickettsiosis), there may only be slight bruising at bite sites in Congo fever.
Unlike many other arbovirus diseases, a high proportion of infections are symptomatic. Onset is usually
very sudden, with severe headache, dizziness, neck pain and stiffness, sore eyes, photophobia, fever, rigor
and chills, followed rapidly by myalgia with intense backache or leg pains, nausea, sore throat and vomiting.
There may be non-localized abdominal pain and diarrhoea at an early stage. Fever is often intermittent
and patients may undergo sharp changes of mood over the first two days, with feelings of confusion and
aggression. By day 2-4 patients may exhibit lassitude, depression and somnolence, and have a flushed
appearance with injected conjunctivae or chemosis. Tenderness localizes in the right upper quadrant of
the abdomen, and hepatomegaly may be discernible. Tachycardia is common and patients may be slightly
hypotensive. There may be lymphadenopathy, plus enanthema and petechiae of the throat, tonsils and
buccal mucosa. A petechial rash appears on the trunk and limbs by day 3-6 of illness, and this may be

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followed rapidly by the appearance of large bruises and ecchymoses, especially in the anticubital fossae,
upper arms, axillae and groin. Oozing of blood from injection or venipuncture sites, epistaxis, haematemesis,
haematuria, melaena, gingival bleeding and bleeding from the vagina or other orifices may commence
on day 4-5 of illness, seldom earlier. There may also be internal bleeding, including retroperitoneal and
intracranial haemorrhage. Severely ill patients enter a state of hepatorenal and pulmonary failure from
about day 5 onwards and progressively becomes drowsy, stuporous and comatose. Jaundice may become
apparent during the second week of illness. The mortality rate is approximately 30% and deaths generally
occur on day 5-14 of illness. Patients who recover usually begin to improve suddenly on day 9-10 of illness,
but asthenia, conjunctivitis, slight confusion and amnesia may continue for a month or longer.

Clinical pathology of Congo fever

During the first few days of illness there may be leucocytosis or leucopenia, and elevated aspartate
and alanine transaminases, gamma-glutamyl transferase, lactic dehydrogenase, alkaline phosphatase
and creatine kinase levels, while bilirubin, creatinine and urea levels increase and serum protein levels
decline during the second week. Thrombocytopenia, elevation of the prothrombin ratio, activated partial
thromboplastin time, thrombin time, elevation of D-dimers and fibrin degradation products, as well as
depression of fibrinogen and haemoglobin values are evident very early in the illness, indicating that
disseminated intravascular coagulopathy is an early and central event in the pathogenesis of the disease.
During the first 5 days of illness any of the following clinical pathology values are highly predictive of fatal
outcome: leucocyte counts ≥10x109/L; platelet counts ≤20x109/L; AST ≥200U/L; ALT ≥150U/L; APTT ≥60
seconds; and fibrinogen ≤110mg/dL. Leucopenia does not have the same poor prognostic connotation as
leucocytosis at this early stage, and all clinical pathology values may be grossly abnormal after day 5 of
illness without necessarily being indicative of a poor prognosis. Viraemia is usually detectable during the
first week of illness (range 1-13 days), and viral nucleic acid can be detected in serum by RT-PCR for up to
16 days after onset. Antibody response is rarely demonstrable in fatal illness, and thus detection of antibody
is generally a favourable sign.

3.2.2 Rift Valley Fever (RVF)

RVF is a mosquito-borne virus disease of livestock in Africa and Madagascar which affects mainly sheep
and cattle, and causes massive outbreaks of abortion and death of young animals at irregular intervals
of years when particularly heavy rains favour the breeding of the vectors. Humans acquire infection from
contact with infected tissues of farm animals, or less frequently from mosquito bite. Most patients experience
benign illness with fever, some with ocular sequelae (usually transient scotomas, but sometimes permanent
blindness) and only <1% develop fatal haemorrhagic disease, hepatitis or encephalitis. Nevertheless,
outbreaks can be massive and the disease has caused large numbers of human deaths on occasion. The
last major outbreak in South Africa occurred in 2010, and particularly affecting farms in Eastern Cape, Free
State and Northern Cape Provinces with some spread to the Western Cape, North West and Gauteng
Provinces. There were 230 lab confirmed human cases and 26 deaths but is likely that there were a
significant number of asymptomatic cases who were not tested. In 1985, one patient infected in Angola
and two infected in Zambia were treated in South Africa. In 2000-1, the disease was recognized outside of

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the African region for the first time in a large outbreak in Saudi Arabia and Yemen. Curiously, there are no
records of human-to-human transmission of the virus, although very high levels of virus occur in the blood
of patients so that transmission by needle stick is possible. An experimental human vaccine produced in the
USA was formerly used on a limited scale in people with occupational exposure to infection in the livestock
industry and in laboratories, but it is not currently available.

Clinical features of RVF

The incubation period is generally 2-6 days, and the majority of infections are either mild (recognized only
in serosurveys or as laboratory infections), or present as moderate to severe febrile illness with sudden
onset of severe retro-orbital pain and headache, photophobia, suffused conjunctivae, myalgia, arthralgia,
prostration, nausea and tenderness of the liver without hepatomegaly. Fever and prostration often last only
2-3 days, or the disease may run a diphasic course over two weeks. Ocular complications occur in 5-20%
of cases 1-3 weeks after onset of illness. Decreased visual acuity or scotomas are associated with retinal
haemorrhages, exudate and macular oedema. Vision usually improves over a period of 1-3 months as
lesions resolve, but occasionally there can be detached retina and blindness. Less than 0.5% of patients
develop encephalitis or haemorrhagic disease with high death rates. Encephalitis occurs as a complication
1-2 weeks after the acute febrile disease, and patients may succumb or undergo sudden or protracted
recovery. Haemorrhagic fever with or without neurologic disease, can supervene within a week after the
acute febrile stage. There is extensive liver necrosis in these cases, and there may be marked anaemia
following massive epistaxis, haematemesis and melaena. Petechiae, ecchymoses and jaundice may be
evident.

Clinical pathology of RVF

There is usually leucopenia, hyperbilirubinaemia, thrombocytopenia, prolongation of clotting parameters

and markedly raised serum transaminases. Viraemia commonly lasts 2-3 days but has been recorded for
up to 11 days.

3.2.3 Chikungunya, Yellow fever and Dengue viruses

These viruses circulate between mosquitoes and non-human primates (monkeys and apes) in forests,
but have the unusual ability among arboviruses of utilizing humans as their sole vertebrate hosts in urban
outbreaks of disease. Although infections with these three viruses can take a haemorrhagic form, they have
not been associated with human-to-human spread, and their main importance is as differential diagnoses
for VHF.

3.2.3.1 Chikungunya (CHIK)

Chikungunya (CHIK) virus causes outbreaks of illness characterized by fever and joint pain in rural
locations where baboons and monkeys occur in Africa, mainly in East Africa, but including South Africa,
particularly the Limpopo and Mpumalanga Lowveld, and northern KwaZulu-Natal coast. Pain in a
particular joint may last for up to two years after the acute illness. Severe and haemorrhagic forms of

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 the disease have been recorded in a minority of patients in Asia and the Indian Ocean islands where the
virus causes large urban epidemics. Chikungunya has been diagnosed in South African tourists returning
from abroad, and it is theoretically possible that such a patient could initiate urban outbreaks involving
transmission by local mosquitoes, particularly in KwaZulu-Natal. There is no vaccine.

3.2.3.2 Yellow fever

Yellow fever (YF) is a well-known mosquito-borne virus, which causes outbreaks of fatal disease with
necrotic hepatitis in South America, West Africa, and less frequently East Africa, but it has never been
recorded south of Angola. Suitable mosquito vectors occur in eastern South Africa. The fact that a very
effective vaccine is available, and is used on international travellers, tends to limit the potential for tourists
to spread infection to remote locations, but it is possible that sick patients could be evacuated for treatment
in South Africa. Nosocomial infection has never been described, although in endemic areas mosquito
transmission could also affect health care workers.

3.2.3.3 Dengue
Dengue (DEN) is a mosquito-borne virus which causes massive outbreaks of disease with fever, and joint
and muscle pains throughout the tropics in South America, the Caribbean, East and West Africa, Indian
Ocean islands, India and South East Asia. There are four sub-types of the virus, and a small proportion
of patients may develop haemorrhagic disease or a shock syndrome, particularly the very young and
the aged, or those who suffer sequential infection with a second sub-type of the virus after an interval
when immunity to the initial infection is waning. This latter phenomenon involves so-called immune-
enhancement of infection. Suitable mosquito vectors exist in eastern South Africa, and it is theoretically
possible for the virus to be introduced into the country and for epidemics to occur here. The disease has
been diagnosed in South Africa on a few occasions in recent years in people who had visited India, the
Far East, or Indian Ocean islands. There is no vaccine.

3.3 Viruses believed to be associated with bats

There is emerging evidence that the filoviruses (filament-shaped or thread-like viruses), Marburg (MBG)
and Ebola (EBO), are associated with bat reservoir hosts. Outbreaks of human disease have sometimes
resulted from known contact with infected tissues of non-human primates (chimpanzees and gorillas), but
since these animals are equally as susceptible to fatal infection as are humans, it is surmised that they are
unlikely to be reservoir hosts. Marburg virus appears to be confined to Africa, whereas the Reston sub-type
of Ebola virus, which apparently causes benign infection in humans, was discovered in monkeys imported
into the USA from the Philippines. In Africa, Marburg and Ebola viruses appear to be endemic in the tropical
region roughly within the area enclosed by Zimbabwe, Angola, Ivory Coast and Kenya: Marburg outbreaks
are known to have originated in Uganda, Kenya, DRC, Zimbabwe and Angola, while outbreaks caused by
the Sudan, Zaire and Ivory Coast sub-types of Ebola virus have occurred in Sudan, Democratic Republic of
Congo, Uganda, Gabon, Congo Republic and Ivory Coast. Two young Australians who are thought to have
become infected while hitchhiking in Zimbabwe, developed Marburg disease in South Africa in 1975, and a
nurse in Johannesburg acquired infection from them. A doctor, who became infected from contact with Ebola
patients in Gabon in 1996, came to South Africa for treatment, and a nurse acquired fatal infection from him.

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 3.3.1 Clinical features of Marburg and Ebola fevers

The incubation period is generally 7-10 days (range 2-21 days) and the duration of clinical disease is
of similar duration, but convalescence is prolonged. There is sudden onset of fever, severe headache
(often frontal initially), sore throat, chest and/or abdominal pain, myalgia, arthritis, malaise, fatigue, nausea
and anorexia. Signs exhibited by patients include oral/throat lesions, persistent diarrhoea and vomiting,
dehydration, dry cough, conjunctivitis and non-itching maculopapular rash of trunk and limbs with onset
on about day 5 of illness and desquamation 4-10 days later. The rash may be difficult to discern in dark-
skinned patients, but the desquamation is more apparent and may involve palms and soles. There may be
splenomegaly and non-icteric hepatitis with epigastric tenderness. Pregnant women may abort. The more
severe and fatal cases progress to a haemorrhagic state by day 5-8 of illness with bleeding from needle
puncture or scarified sites, mouth/gingival bleeding, haematemesis, melaena and epistaxis. Central nervous
system symptoms include aggressive and altered behaviour, confusion and somnolence. Dehydration is
severe in the absence of administration of fluids.

Clinical pathology of Marburg and Ebola fevers

There may be transient leucopenia followed by marked leucocytosis, reduced platelet counts, raised
transaminases, proteinuria and low haemoglobin values. Viraemia has been detected up to day 17 of illness,
but persistence of virus has been demonstrated in some organs (liver, and eye with uveitis) for several
weeks, and excretion in semen has been recorded for up to 12 weeks after onset of illness

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Table 1: Viral haemorrhagic fevers and certain related infections

Family Genus Virus Human disease Vectors Vertebrate hosts Distribution

Rodent-associated viruses
Arenaviridae Arenavirus Lassa Lassa fever Rodents W Africa
Lujo Lassa-like Rodents? Southern Africa?
Several other S. American VHFs Rodents S America
Bunyaviridae Hantavirus
Several Asian &
HFRS Rodents Asia & Europe
European
Several N & S
HPS Rodents N & S America
American
Arthropod-borne viruses

Bunyaviridae Phlebovirus Rift Valley fever Rift Valley fever Mosquitoes Ruminants Africa, Madagascar

Crimean-Congo Ruminants & small

Nairovirus Crimean-Congo HF Ixodid ticks E Europe, Asia, Africa
HF mammals
Alphaviridae Alphavirus Chikungunya Chikungunya Mosquitoes Monkeys Africa, Asia
Flaviviridae Flavivirus Yellow fever Yellow fever Mosquitoes Humans & monkeys S America, W & E Africa
Dengue I, II,
Dengue I, II, III, IV Mosquitoes Humans & monkeys Caribbean, W & E Africa
III, IV
Omsk HF Omsk HF Ixodid ticks Rodents Siberia, Roumania?
Kyasanur Forest Kyasanur Forest
Ixodid ticks Unknown India, Pakistan
disease disease
Alkhurma Alkhurma Ixodid ticks Camels, sheep Saudi Arabia (Near East?)
Viruses believed to be associated with bat reservoir hosts
Filoviridae Filovirus Marburg Marburg disease Bats Africa
Ebola-Zaire Ebola HF Bats? Africa
Ebola-Sudan Ebola HF Bats? Africa
Ebola-Ivory
Ebola HF Bats? Africa
Coast
Non-pathogenic for
Ebola-Reston Bats? Philippines
man?

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 4. Diagnosis

4.1 Clinical diagnosis of VHF

Signs and symptoms of VHF

Early signs and symptoms are non-specific, and patients may present with fever, headache, conjuctivitis,
pharyngitis, myalgia (especially lower back pain), vomiting, abdominal pain and diarrhoea. Recognition of
the syndrome is easier once patients develop a petechial rash or ecchymoses, and other haemorrhagic
signs such as epistaxis, haematemesis and melaena. There may be rapid progression to multi-organ failure,
altered mental state, jaundice and shock.

Important information to bear in mind during clinical diagnosis

Not all patients with VHF bleed, and it is more important to recognize a syndrome that may include
bleeding, nosocomial transmission, evidence of thrombocytopenia and hepatic dysfunction, notably raised
transaminases.

Clinicians can seek advice from the medical officer on duty at the National Institute for Communicable
Diseases (NICD) (cellular telephone number 082 883 9920).

More than 90% of suspected cases of VHF prove to be severe forms of common diseases. Many of the
diseases mistaken for VHF are treatable if diagnosed early. There must be systematic elimination of differential
diagnoses (see section 4.2).

Failure to institute appropriate safety precautions can have severe consequences. However, the unnecessary
institution of isolation precautions is expensive and highly disruptive.

By the time that VHF is suspected patients have often received prior medical attention during which certain
clinical pathology and microbiological tests may have been performed (see section 4.2).

Obtaining a history of possible exposure to infection can be crucial to diagnosing VHF. Relatives and cohorts
often provide more reliable information than severely ill patients.

Detailed and accurate information required during diagnosis

• Age, sex, and place of residence of the patient (VHF infection has not yet been confirmed
to have occurred within South Africa in a child <10 years old).
• Chronic medical conditions and medication, including recent drug and dosage adjustments.
• History of the current illness, including results of prior medical and laboratory investigations.
• Occupation of the patient and possible exposure to infection as in:
- Health care and laboratory workers who tended, or processed specimens from, patients with
confirmed or suspected VHF or undiagnosed fever compatible with VHF; and
- Contact with animals or animal tissues by abattoir workers, veterinarians, farm workers, hunters,
taxidermists, or persons who work with hides and skins.
• Non-occupational contact with known or suspected cases of VHF, or undiagnosed fever.

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 • Non-occupational contact with animals or their tissues including blood.
• Residence in or recent travel to tropical or rural environments.
• Handling or being bitten by ticks or insects, especially mosquitoes.
• Recent travel to a country known or likely to be endemic for VHF, particularly involving rural environments
and contact with animals or insects - but remember that some rodent-associated and mosquito-borne
VHF viruses can occur in urban environments (see section 3).
• Record exact details of:
- The date/s of potential exposure/s to infection.
- The date of onset of illness (incubation periods are <1 week for arbovirus infections including Congo
fever, but up to 3 weeks for arenavirus, hantavirus and filovirus infections - see section 3).
- The dates and types of all specimens previously taken and submitted for laboratory examination.
- The results of all clinical pathology and microbiological tests already performed (see section 4.2).

Features that support a diagnosis of VHF

• Short duration and rapid progression of the disease: i.e. acute rather than chronic illness.
• Lack of evidence in the patient’s history or physical examination, which excludes VHF.
• Laboratory evidence of leucopenia, thrombocytopenia, coagulation abnormalities, and raised serum
transaminases, but leucocytosis can occur in CCHF, Lassa, Marburg and Ebola haemorrhagic
fevers, and relatively normal platelet counts can be seen in Lassa fever.
• The progression of the illness and the timing of bleeding in relation to the onset of symptoms may
be important in guiding the diagnosis of VHF versus alternative diagnosis. For example: patients with
Congo fever typically bleed three to five days after the onset of illness while patients with meningococcal
disease typically bleed within 24 hours after the onset of symptoms.

Features which tend to exclude a diagnosis of VHF

Normal platelet counts and normal serum transaminase levels render VHF unlikely. Confirmation of an
alternative diagnosis, e.g. a positive blood culture may also render VHF unlikely. However, it is important
to remember that bacterial septicaemia can occur as a complication to VHF, and in areas where malaria
is endemic patients may test positive for malaria on blood smears while suffering from other infections,
including VHF.

A scoring system found to be useful in the diagnosis of Congo fever in South Africa is presented in Table 2,
and a document on answers to frequently asked questions about the disease, compiled for people involved
in the livestock industry, is included as Appendix 1.

The outcome of the initial assessment may be inconclusive, but the aim should be to decide whether or not to
proceed on the assumption that VHF may be involved. The disruptions and expense caused by false alarms
should be balanced against the potentially dire consequences of failure to recognize VHF.

For submission of specimens for specific laboratory confirmation of VHF see section 4.3.

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 Table 2: Criteria for clinical diagnosis of Crimean-Congo haemorrhagic fever. R Swanepoel,
JH Mynhardt and S Harvey 1987

Incubation period following

known or potential exposure:
1 week or
<l week
undetermined

I. HISTORY OF EXPOSURE TO INFECTION:

3 2**
Bitten by tick/s or crushed tick/s with bare hands
OR
3** 2***
Had direct contact with fresh blood or other tissues of live
stock or game animals
OR
3 2
Had direct contact with blood, secretions or excretions of
confirmed or suspected CCHF patient (including needle
pricks)
OR
2 1
Resided in or visited a rural environment where contact
with livestock or ticks was possible, but a specific incident
constituting exposure cannot be identified

II. SIGNS AND SYMPTOMS:

1
Sudden onset
1
Fever 38℃ on at least one occasion
1
Severe headache
1
Myalgia
1
Nausea and/or vomiting
3
Bleeding tendency: petechial rash, ecchymoses, epistaxis,
haematemesis haematuria or melaena

III. CLINICAL PATHOLOGY DURING FIRST 5 DAYS OF

ILLNESS:
1
Leukopaenia or leukocytosis
WCC<3 x 109/1 or 9 x 109/1

Thrombocytopaenia
1
Platelets < 150 x 109/L
2
Platelets < 100 x 10/L
OR
1
50% decrease in either
WCC or platelet counts within 3 days
1
Abnormal PI
1
Abnormal PTT

Raised transaminases
1
AST 100 U/L
1
ALT 100 U/L

*South African tick-borne typhus and ehrlichiosis must be excluded.

**Rift Valley fever and anthrax must be excluded.
***Brucellosis, Q fever and anthrax must be excluded.

A total score of 12 points or more constitutes an indication for treating a patient as a case of CCHF.

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4.2 Differential diagnosis of suspected VHF

4.2.1 Procedure to follow when VHF is suspected

When VHF is suspected, it is important to obtain and interpret the results of all medical examinations and
laboratory tests already performed, but warn laboratory personnel of the suspected diagnosis and ensure
that further laboratory tests are only performed with appropriate biosafety precautions (see section 6.2).
Another crucial step to take is to ensure that all specimens previously submitted to laboratories are retained
for onward transmission to NICD along with newly collected specimens for specific VHF diagnostic tests
(see.section 4.3).

4.2.2 Diseases commonly confused with VHF

a) Malaria, trypanosomiasis, relapsing fever, plague, yellow fever, other arbovirus infections and
leptospirosis, especially after travel to or residence in rural or tropical areas (malaria is most common
and can be rapidly fatal if not treated, but it also occurs together with other infections including VHF).

b) Bacterial septicaemias resemble VHF and can be rapidly fatal if not treated; most commonly caused
by meningococci, but also by a wide variety of Gram-positive and -negative bacteria, and include
typhoid, anthrax, and Capnocytophaga species (dysgonic fermenter 2) infection after dog bite, (septic
abortion and tuberculosis with haemoptysis can also resemble VHF).

c) Rickettsioses: tick bite fever (TBF), Q fever, typhus; TBF often occurs in town dwellers who visit
rural environments, but can also result from exposure to kennel ticks in urban settings, even where
dogs are kept indoors in apartment buildings; TBF can run a fatal course very similar to Congo fever,
but has an incubation period of 7-10 days after tick bite as compared to 1-3 days for Congo fever,
there is usually a necrotic eschar at the site of the tick bite in TBF and the petechial rash extends to
palms and soles; TBF can be treated with broad-spectrum antibiotics.

d) Hepatitis A, B, E, and less often C (westerners travelling in Africa often develop hepatitis A).

e) Fulminant systemic herpes simplex virus infection with hepatitis (with/without vesicular rash);
about 60 cases have been seen in RSA with high fatality, mostly in ostensibly healthy young adults;
extremely high transaminase levels which may fall terminally after virtually complete destruction of
hepatocytes. Less common are severe cytomegalovirus, E-B virus or varicella-zoster virus
infections, or haemorrhagic measles.

f) HIV seroconversion sickness, or HIV/AIDS with secondary infections, especially septicaemias.

g) Drug sensitivities and overdoses including anticoagulants (warfarin), other poisons and toxins
including haematoxic snake bite envenomation (e.g. boomslang), industrial and agricultural
chemical poisoning.

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h) Malignant disease, e.g. leukaemia, lymphoma.

i) Idiopathic thrombocytopenic purpura.

j) Heat stroke.

4.2.3 Interpretation of clinical pathology results for differentiating VHFs from other diseases

a) Full haematological examination: Findings compatible with VHF include leucopenia,

thrombocytopenia, anaemia, altered clotting parameters and increased fibrin degradation products
or D-dimers, but disseminated intravascular coagulopathy also occurs in many other conditions,
including septicaemia. Granulocytosis suggests bacterial infection, but leucocytosis can occur in
CCHF, Lassa, Marburg and Ebola haemorrhagic fevers (see section 3), and in leukaemia.

b) Examination of a stained blood smear: Malaria, trypanosomiasis, other haemoparasitic diseases

and certain bacterial septicaemias (meningococcus, Capnocytophaga, anthrax) can be diagnosed,
and differential white cell counts can be performed to provide an indication of leucocytosis/
granulocytosis, leucopenia, leukaemia, anaemia, and even thrombocytopenia.

c) Bacteriological blood cultures: It is important that blood cultures should be performed to exclude
septicaemia. Samples should be taken before antibiotic therapy is instituted. Septicaemia can be
secondary to many conditions including pneumonia, gastroenteritis, perforated ulcers, and abscesses
or wound infections.

d) Clinical chemistry tests: Raised serum transaminase levels occur commonly in VHF, and to a lesser
extent also raised bilirubin levels, but jaundice and hepatocellular damage have many causes.
Extremely high transaminase and bilirubin levels occur in systemic herpes simplex infection with
hepatitis. Evidence of severe liver damage is a poor prognostic sign. Proteinuria is common in VHFs,
notably in Lassa fever.

e) Specific serodiagnostic tests for non-VHF diseases: Serological tests results should be interpreted
with caution, taking into account the sensitivity and specificity of the test and the stage that they are
performed during the course of the illness. Notably negative results using the currently available tests
for tick bite fever may not exclude the disease. Anti-HA IgM, HbsAg, HBeAg and Anti-HBc are important
screening tests for hepatitis A and B. Serodiagnostic tests are available for leptospirosis, salmonellosis,
measles, herpesvirus infections and many other diseases which could be confused with VHF. Rapid
serum latex agglutination tests can be used to detect bacterial antigen in meningococcal septicaemia.

Primary specimen containers such as blood tubes (properly labeled) should be wrapped in sufficient
absorbent material (paper towels or tissues) to absorb the entire contents in the event of leakage.

The wrapped primary containers must be placed in durable, leak-proof secondary containers such as

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 several layers of sealed plastic bags or, preferably, rigid screw-cap metal, plastic or similar containers
(suitable containers are usually available from hospital dispensaries). The secondary container should be
taped closed to prevent leakage.

The secondary containers and data forms, sealed separately in plastic, must then be placed in a rigid outer
(tertiary) container such as a fibre carton or polystyrene cold box with cold packs. Specimens, particularly
whole blood, should not be frozen.

The outer wrapping should be addressed to The Special Pathogens Unit, National Institute for
Communicable Diseases, Street address: 1 Modderfontein Road, Sandringham, Johannesburg.
Postal address: Private Bag X4, Sandringham, 2131
Contact telephone numbers: 011 386 6339, 082 903 9131, 082 908 8042, or 082 908 8046: NICD
Hotline 082 883 9920.

The parcel should bear appropriate outer warning that it contains biohazardous material by means of
stickers AW 285 and AW 285A with the international biohazard symbol available at freight offices or airport
cargo facilities (Figure 4.3).

In addition to completing an ordinary air waybill for parcels sent by air, it is necessary to complete a shipper’s
declaration for dangerous goods (document AW 349) (Figure 4.4).

Specimens must be accompanied by at least the following information:

 Name, age, sex and occupation of the patient, place of residence (town/farm), history of recent travel
away from home, contact with animals, known insect bites, suspected diagnosis, date of onset of
illness, brief clinical features, date on which specimens were taken, and treatment administered
(antibiotics, immune plasma, antivirals and other drugs). This information is essential to allow SPU
staff to determine which tests are most appropriate.
 The legible name of a clinician who bears knowledge of the case and telephone numbers where
this person may be contacted during and after work hours. This facilitates communication and
allows quick reporting of findings.
 All of the requisite information can be furnished concisely by completing a photocopy of the VHF
laboratory investigation request form (Figure 4.5).

More than one pathology may be present in a patient, and epidemiological information and clinical laboratory
findings should guide the diagnostic process.

4.3 Laboratory verification of VHF

Specific diagnostic tests for the formidable (Class 4) VHFs are performed only by the Special Pathogens
Unit (SPU) at NICD. It is essential that arrangements are made directly with one of the SPU laboratory
diagnosticians before specimens are submitted (Laboratory telephone numbers 011 386 6339, 082 903
9131, 082 908 8042 and 082 908 8046; NICD Hotline 082 883 9920), particularly where urgent investigations

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are warranted after normal work hours (07h30-16h00 Monday to Friday). The staff must be informed of the
means of transport of the specimens, tracking or waybill numbers, and expected date and time of delivery.

4.3.1 Source and nature of specimens:

Clinical laboratories

All specimens that may have been submitted to haematology, microbiology, clinical chemistry and other
laboratories before VHF was suspected must be traced and redirected to NICD for virological examination.
These specimens are important because VHF viruses are often only present in blood and other tissues in
the early stages of the disease, and may be absent later.

Live patients

Specimens to be taken from live patients specifically for the investigation of suspected VHF should include
5-10ml of clotted blood and 5ml of blood taken with EDTA/sequestrene (lavender top). Throat swabs in viral
transport medium may also be useful. Daily samples collected from patients in whom a diagnosis of VHF
has already been confirmed provide valuable information, but need not be submitted for urgent tests; the
samples can be kept refrigerated and sent to NICD in batches by routine laboratory delivery services with
appropriate packaging (see 4.3.2 below).

Corpses

There is usually reluctance to proceed with a full autopsy until VHF can be excluded, and there is a widespread
misconception that post mortem procedures may only be performed with the consent of relatives. However,
in terms of the Health Act 61 of 2003 autopsy and removal of organs or tissues ‘for determining the cause
of death’ may be authorized by the medical practitioner in charge of clinical services in the hospital or
authorized institution, or of the mortuary, or by a medical practitioner authorized by the person in charge
of such hospital or authorized institution. Minimal specimens taken to eliminate VHF should include blood
collected by cardiac puncture and liver samples taken with a biopsy needle; some liver should be placed in
fixative for histopathological examination and some placed in a small volume of viral transport medium or
physiological saline for virological examination. If possible, some liver tissue should also be placed in 2.5%
glutaraldehyde fixative for electromicroscopy. The specimens can be taken in the ward where the death
occurred or in a mortuary. Blood tends to ooze from needle puncture sites and these should be taped or
sealed (e.g. Opsite®, S & N Pharmaceuticals Pty Ltd). The body should be decontaminated and sealed in
double stout plastic body bags as discussed in section 6.5.

Labels attached directly to the primary specimen containers (e.g. blood tubes) should be marked clearly
with the name of the patient and date of collection of the sample. For removal from the patient facility or
mortuary, the specimens should be double-wrapped in zip-lock specimen bags or ordinary clear plastic
bags and labeled appropriately, preferably with biohazard stickers to alert staff to the contents, and should
be delivered by hand directly to the laboratory responsible for forwarding the specimens to NICD. It may

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 be useful to have a histopathologist examine rapidly fixed (heated formalin) and sectioned liver specimens.
Bacterial septicaemia can sometimes be recognized and differentiated from liver disease due to VHF or
other causes. Lack of liver lesions suggests that VHF is not involved.

4.3.2 Packaging of specimens for transfer to NICD

UN/WHO approved shipping containers for hazardous specimens are commercially available, e.g. SAF-T-
PAK®, or else safe packaging can be improvised as indicated in the text box below (Figures 4.1; 4.2):

Primary specimen containers such as blood tubes (properly labeled) should be wrapped in sufficient absorbent
material (paper towels or tissues) to absorb the entire contents in the event of leakage.

The wrapped primary containers must be placed in durable, leak-proof secondary containers such as several
layers of sealed plastic bags or, preferably, rigid screw-cap metal, plastic or similar containers (suitable
containers are usually available from hospital dispensaries). The secondary container should be taped closed
to prevent leakage.

The secondary containers and data forms, sealed separately in plastic, must then be placed in a rigid outer
(tertiary) container such as a fibre carton or polystyrene cold box with cold packs. Specimens, particularly
whole blood, should not be frozen.

The outer wrapping should be addressed to The Special Pathogens Unit, National Institute for
Communicable Diseases, Street address: 1 Modderfontein Road, Sandringham, Johannesburg.
Postal address: Private Bag X4, Sandringham, 2131. Contact telephone numbers: 011 386 6339, 082
903 9131, 082 908 8042, or 082 908 8046: NICD Hotline 082 883 9920.

The parcel should bear appropriate outer warning that it contains biohazardous material by means of stickers
AW 285 and AW 285A with the international biohazard symbol available at freight offices or airport cargo
facilities (Figure 4.3).In addition to completing an ordinary air waybill for parcels sent by air, it is necessary to
complete a shipper’s declaration for dangerous goods (document AW 349) (Figure 4.4).

Specimens must be accompanied by at least the following information:

 Name, age, sex and occupation of the patient, place of residence (town/farm), history of recent travel
away from home, contact with animals, known insect bites, suspected diagnosis, date of onset of
illness, brief clinical features, date on which specimens were taken, and treatment administered
(antibiotics, immune plasma, antivirals and other drugs). This information is essential to allow SPU
staff to determine which tests are most appropriate.
 The legible name of a clinician who bears knowledge of the case and telephone numbers where
this person may be contacted during and after work hours. This facilitates communication and
allows quick reporting of findings.
 All of the requisite information can be furnished concisely by completing a photocopy of the VHF
laboratory investigation request form (Figure 4.5).

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The method used for transmitting specimens to NICD depends on the urgency with which diagnostic tests
are required, proximity to NICD, and the availability and speed of routine delivery services for transmitting
specimens to NICD as operated by the National Health Laboratory Service (NHLS) and private companies
(e.g. Ampath, Lancet)

For the delivery of specimens for urgent tests from within a few hours distance by road from NICD, it may
be necessary to assign a specific vehicle and driver. This applies even to hospitals within close proximity to
NICD since routine specimen delivery routes are operated at certain times of day only. Sometimes relatives
of patients are willing to deliver specimens when no other rapid means of transport is available. Specimens
should be delivered directly to members of SPU staff (contact telephone numbers: 011 386 6339, 082
903 9131, 082 908 8042, 082 908 8046; NICD Hotline 082 883 9920), or after hours left with the security
guards at the entrance to NICD by prior arrangement with SPU staff (for map see Figure 4.6).

For delivery of specimens from longer distances it may be possible to utilize routine laboratory delivery
services, or a commercial courier service using scheduled road or air transport and door-to-door delivery,
depending on the urgency with which tests are required. However, deliveries after normal work hours, and
particularly at weekends, can be difficult to arrange.

Follow up specimens from patients in whom the diagnosis has already been confirmed or sera from healthy
contacts of VHF patients which are sent for routine screening and do not require urgent tests, can be sent
to NICD by regular laboratory delivery services with appropriate packaging.

4.3.3 Laboratory tests

If emergency tests are warranted and appropriate arrangements have been made ahead of time with SPU
staff (telephone numbers 011 386 6339, 082 903 9131, 082 908 8042 and 082 908 8046; NICD Hotline
082 883 9920) tests can be performed after normal work hours, which are 07h30-16h00 on weekdays only.

4.3.4 Interpretation of results

In the acute phase of the disease, cases of VHF are diagnosed by identifying virus antigen or nucleic
acid in the specimens, or by isolating (culturing) live virus. Virus antigen detection tests are used for certain
diseases only and take 3-8 hours to complete. Detection of virus nucleic acid by reverse transcription-
polymerase chain reaction (RT-PCR) takes 6-12 hours from the time of receiving the specimen in the
laboratory, depending on whether or not there is need for nested (second round) tests. Isolating virus in
culture can sometimes be achieved within 2 days but usually takes a week or longer.

In the convalescent phase of the disease, cases of VHF are diagnosed by identifying an antibody
response. Preliminary IgG antibody tests can be completed within two hours of receipt of specimens and
IgM tests within 3 hours, but overnight tests produce more reliable results.

All serum samples (acute and convalescent) are routinely tested for antibodies to the full range of African

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VHF viruses. This is because the clinical histories received are sometimes inaccurate, particularly with
respect to the date of onset or duration of illness.

It is extremely important to remember that even acute specimens for which virus antigen, RT-PCR
and antibody tests are all negative, occasionally yield virus in culture some days later. Failure to
appreciate this possibility has led to serious misunderstandings in the past.

Sometimes it is necessary to submit a further sample to clarify an ambiguous finding. For example, detection
of IgG antibody on its own, without virus or IgM antibody, could indicate past infection not connected to the
current illness, but sometimes IgG can appear in circulation slightly before IgM during convalescence.

It is almost equally important to eliminate a possible diagnosis of VHF as it is to confirm a diagnosis rapidly:
failure to detect virus or viral nucleic acid in serum during the first 7 days of illness, or to demonstrate
antibody two weeks after onset, constitutes a fair indication that one of the known African VHFs is not
involved. However, viraemia may be of very short duration or absent. Hence, negative findings on samples
taken early in the course of disease should be supported by antibody tests on further specimens taken in
convalescence.

In emergencies results are made known telephonically or by fax as soon as possible, with written confirmation
following later (remember to include contact details for the person to whom results should be reported
when submitting specimens).

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 Figure 4.1: Example of commercially available specimen biosafety packaging.

Figure 4.2: Example of improvised specimen biosafety packaging.

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Figure 4.3: International biohazard symbol stickers AW 285 and AW 285A

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 Figure 4.4: IATA shipper’s declaration for dangerous goods (document AW 349).

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Figure 4.5: VHF laboratory investigation request form

Figure 5: VHF laboratory investigation request form

NATIONALINS
TITUTEFORC
O MMUNIC
ABLEDIS
EAS
ES
of the NATIONAL HEALTH LABORATORY SERVICE
NICD
Practice No. 5200768

SPECIAL PATHOGENS UNIT

1 Modderfontein Rd, Sandringham, Johannesburg; Private BagX4, Sandringham 2131, South Africa

Special Pathogens Unit SPU laboratory diagnostician SPU laboratory diagnostician Head of SPU
Tel 0027 (0)11 386 6000/6382 Cell 082 903 9131 Cell 082 908 8042 Cell 082 908 8045
Fax 0027 (0)11 882 3741

REQUEST FORM: INVESTIGATION OF SUSPECTED VIRAL HAEMORRHAGIC FEVER

Completed form must accompany specimens

Referring doctor .................................................. Patient ................................................................

Address ............................................................... Age ................................Sex...............................

............................................... Code .................. Hospital number...................................................

Tel (W) ............................................................... Hospital ...........................................Ward...........

Tel (A/H or cellular) ........................................... Date of admission ..............................................

Fax...................................................................... Medical fund ............................. No...................

Account to: ................................................................................................................. Code ..............

Specimen/s ..............................................................................................Date taken ...........................

Disease suspected/tests required...........................................................................................................
Possible exposure to viral haemorrhagic fever (e.g occupation, urban or rural resident, history of travel,
contact with animals or human patient, insect/tick bites - give dates).........................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
N.B. ACCURATE DATE OF ONSET OF ILLNESS....................................................................................
Clinical history and examination .................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
Treatment (antibiotics/antimalarials)..............................................................................................................
........................................................................................................................................................................
Results of laboratory investigations already performed:
Date

Total leukocytes
Differential %N/L

Platelets

Haemoglobin

Coagulation test/s

ALT

AST

Malaria parasites

Blood culture

World Health Organization Collaborating Centre Complies with

for Haemorrhagic Fevers & Arbovirus Diseases. ISO 17025 1999
Member of the Regional EPI Laboratory Network No. M 0029
in the capacity of a Regional Reference Laboratory

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 Figure 4.6: Map showing physical location of the National Institute for Communicable Diseases.

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 5. Immediate Action To Be Taken After Clinical Diagnosis Of VHF

As soon as the decision is made to proceed on the basis of a presumptive diagnosis of VHF, measures
should be applied to minimize exposure of medical staff, other patients and relatives. Whatever is ultimately
decided concerning the management of the case, the immediate course of action should be to:
• Inform the management and infection control officers at the medical facility concerned of the existence
of the suspected case of VHF.
• Isolate the patient and apply infection precautions as best as can be managed under the circumstances
in cooperation with infection control staff (see section 6.3). The precautions must remain in force until
the possibility of VHF has been excluded or the patient is no longer under care at the facility concerned.
• Administer such life-saving therapy as may be necessary and possible, e.g. blood/fluid therapy.
• Take steps to verify the diagnosis (see sections 4.3).
• Cooperate with infection control officers in preparing a list of staff members who have had contact with
the patient or fomites, including ambulance, laboratory and cleaning personnel - the contacts must be
informed of the risks and precautions to be taken, and placed under observation (see section 7 for
definitions of exposure, contact and observation).
• Notify the National Director of Communicable Disease Control (CDC) and the relevant Provincial
Coordinator of CDC of the existence of the suspected case of VHF so that they can investigate the
circumstances surrounding the incident, place relatives and cohorts and other contacts of the patient/s
under observation if indicated, and take necessary actions to control any potential outbreak of VHF in
the community at large (see section 7.2 for contact details of the officials).
• Decide whether the patient is to be retained at the primary hospital, or whether to seek transfer to
a hospital more suited to managing the case. Decisions to transfer VHF patients cannot be taken
unilaterally; see section 7.1 for the criteria and mechanisms for reaching decisions on referral.
• Assess the status of the patient as either low, moderate or high risk with respect to the probability that
VHF is involved, the likely outcome of the disease, and the feasibility of safe transfer - sometimes
the process of transfer poses too great a threat to the life of the patient or the safety of the personnel
involved:

Low risk patients

This category has febrile disease with features suggestive of VHF (e.g. thrombocytopenia), but are not
necessarily severely ill and lack a history of contact with known VHF patients or animals (other than long-
term pets), or animal tissues, or ticks and mosquitoes, and have not left an urban environment for at least 3
weeks prior to onset of illness. There are no haemorrhages, and risk of spread of infection is assessed as low.

Moderate risk patients

This category has febrile disease with features suggestive of VHF, and are not necessarily severely ill, but
have visited or resided in a tropical or rural environment, or have had contact with animals or animal tissues,
or ticks and mosquitoes during the 3 weeks preceding onset of illness. They have not had direct contact with
known VHF patients or fomites (see section 7.3) but may have an indirect association with such patients,
e.g. they have worked, resided in or visited the same places as VHF patients. Although there may be no
haemorrhages, it is assessed that infection with a VHF agent may be involved.

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High-risk patients

This category is severely ill with fever and haemorrhagic manifestations (this criterion is sufficient to place
patients in the high risk category). In addition, they may have visited or resided in a tropical or rural environment,
or have had contact with animals, animal tissues or ticks and mosquitoes during the 3 weeks preceding onset
of illness. Alternatively, they may not necessarily be severely ill, but have had definite exposure to VHF (see
section 7.3). This includes a) hospital and laboratory staff who have developed illness within 3 weeks* of last
known contact with a confirmed VHF patient or fomites associated with such patients, and b) relatives and
close associates of known VHF patients. (*The interval is 2 weeks for arbovirus diseases such as Congo
fever, but 3 weeks for Lassa, Marburg and Ebola haemorrhagic fevers.)

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 6. Management Of VHF Patients

6.1 Medical management of VHF patients

The medical management of VHF patients is a subject on which it is difficult to obtain consensus of opinion,
and detailed analysis lies beyond the scope of the present document. The following remarks represent an
attempt to summarize experience gained mainly in the management of Congo fever patients in South Africa.
.
6.1.1 Antiviral therapy

Antiviral compounds

Ribavirin is a synthetic nucleoside analogue, which has been shown to be of use in treating hantavirus and
arenavirus (Lassa fever) infections. There is evidence to suggest that it is of benefit in treating Congo fever
patients but the findings are not conclusive, mainly because too few patients have been placed on therapy
sufficiently early in the course of the disease for meaningful analysis: since deaths occur from day 5 of
illness onwards the disease must be recognized and treated early.

In practice, ribavirin therapy has only been attempted in patients with severe disease and a poor prognosis.
In order to reach an early decision to institute therapy, it should be noted that during the first 5 days of
illness in Congo fever any of the following pathological values are predictive of fatal outcome: leucocyte
count ≥10x109/L; platelet count ≤20x109/L; AST ≥200U/L; ALT ≥150U/L; APTT ≥60 seconds; and fibrinogen
≤110mg/dL. After day 5 of illness any value may be grossly abnormal without necessarily being indicative
of a poor prognosis.

The oral preparation of ribavirin is registered in South Africa for the treatment of viral hepatitis. The drug
would therefore be used ‘off- label’ for the treatment of Congo Fever or Lassa fever. The trade name is
Copegus, a Roche product, available in 200mg tablets. Ideally all severely ill patients should be treated
with the intravenous formulation of ribavirin, but unfortunately it is not currently available in South Africa.
It generally has to be sourced and imported when required. Table 6.1 and 6.2 shows the recommended
dosage for adults and children.

Table 6.1: Recommended ribavirin dosage for Lassa- and Crimean-Congo haemorrhagic fevers:
Adults including pregnant women.

Administration Loading dose d1 d1-4 d5-10

17 mg/kg 17 mg/kg 8 mg/kg
IV (6) (max 1000 mg per dose) (max 1000 mg per dose) (max 500 mg per dose)
1x * q 6h q 8h

PO (4) 2000 mg 1x 1000 mg q 6h 500 mg q 6h

* The loading dose for intravenous ribavirin has been suggested in other documents as 30 mg/kg (max
2000 mg per dose) 1x (6, 7).

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 Table 6.2: Recommended ribavirin dosage for Lassa- and Crimean-Congo haemorrhagic fevers:
Children

Administration Loading dose d1 d1-4 d5-10

IV (6) 17 mg/kg 1x 17 mg/kg q 6h 8 mg/kg q 8h

PO (4) 30 mg/kg 1x 15 mg/kg q 6h 7 mg/kg q 6h

Oral ribavirin treatment of CCHF reported by Fisher-Hoch et al. (14): 4000 mg/d d1-4, 2400 mg/d d5-10.

Ribavirin can cause bone marrow depression, raised serum bilirubin values, nausea and malaise, but these
effects are generally overshadowed by the signs and symptoms of VHF. Moreover, the drug is teratogenic
in animal models, but its use should still be considered in pregnant patients given the potential for lethality
in severe infections.

Congo fever patients have generally succumbed or recovered before completion of 10 days of treatment,
resulting in early termination of the treatment.

No other chemotherapeutics are available for the treatment of VHFs, and the use of ribavirin is indicated only
for the treatment of hantavirus, arenavirus and Congo fever virus infections. Use of ribavirin is considered
to be contraindicated in Rift Valley fever as some patients treated in Saudi Arabia in 2000 succumbed to
late-onset viral encephalitis, but the association with ribavirin is not clear.

Prophylactic use of ribavirin

Oral ribavirin has been used prophylactically in persons deemed to have been exposed to infection with
hantaviruses, arenaviruses and Congo fever virus, but the side effects of the drug can cause confusing and
distressing illness which is particularly inconvenient when several people are affected. Hence it is advised
that prophylaxis should be strictly limited to instances where there are strong indications that there has been
exposure to infection, such as needle stick with blood known to be infected. The dosage for prophylaxis is
the same as for treatment of infection.

Interferon

It has been demonstrated that interferons have significant antiviral activitiy against VHF agents in vitro
and in animal models, and that there may be high levels of interferon expression in VHF patients. There
appears to be no information on the value of interferon therapy in VHFs, but it is cautioned that its use in
VHF patients poses difficult clinical challenges.

6.1.2 Immune plasma therapy

There is no controlled experimental evidence to indicate that the use of immune plasma is of benefit in VHF,

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and persons who have recovered from Congo fever generally have low neutralizing antibody activity in their
serum which is unlikely to be of therapeutic value.

6.1.3 Supportive treatment

Monitoring of vital functions

This should include temperature, pulse and respiration rates, chest auscultation and fluid balance (liquid
intake/urinary output). The necessity for and frequency of additional monitoring is dictated by the severity
of the disease/condition of the patient and whether or not a ventilator and drugs such as diuretics are
being used. Laboratory tests to support patient management include full blood counts (with platelet plus
haemoglobin values), coagulation, liver function, glucose, creatinine, urea, electrolyte, blood gases and pH
determinations on appropriate blood samples.

A chest X-ray should be taken on admittance of the patient and repeated if respiratory distress or suspected
secondary infection occurs.

Haemoglobin replacement

This may be considered when blood haemoglobin levels fall to 8-10g/dL, but some patients tolerate such
low levels quite well, and it is more important to treat on the basis of signs and symptoms of anaemia
(respiratory distress) than purely on haemoglobin levels.

Although fresh blood may be transfused, it is better to use red blood cell concentrate to treat the anaemia
of VHF. This helps prevent fluid overload and development of the respiratory distress syndrome. Modern
additives to red cell concentrates adequately maintain the levels of phosphates which modulate the oxygen
affinity of haemoglobin, so it is not essential to use fresh blood. As a rough guide, one unit of red cell
concentrate should raise the haemoglobin level of an average adult by lg/dL.

Treatment of disseminated intravascular coagulopathy (DIC)

Contrary to our earlier perceptions, DIC appears to be an early and prominent feature of CCHF and other
VHFs. There are two views on treatment of DIC: one holds that the administration of coagulation factors
merely ‘adds fuel to the fire’, while the other advocates judicious replacement of coagulation factors. The
latter opinion appears to be most widely favoured.

The use of heparin is considered to be useful in the early hypercoaguable stage of DIC, when there is
accelerated partial thromboplastin time (PTT) and decreased prothrombin ratio (PR), but is of no value
once the fibrinogen level falls. However, most cases of VHF are not diagnosed sufficiently early for use of
heparin to be of value. Moreover, the use of the drug requires constant monitoring of the response and is
best avoided by the inexperienced.

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Thrombocytopaenia is a common feature of VHFs and occurs regularly in CCHF. There is agreement on
the need for replacement of platelets, but this should be done only if thrombocytopaenia is accompanied by
purpura and active bleeding such as epistaxis, or if platelet counts fall below 20x109/L.

A bag of platelet concentrate contains approximately 0.5 - 1.0X10 11 platelets in about 50 ml of plasma.
The dosage of platelet concentrate is 1 bag/10kg body mass and transfusion services can be requested
to pool the total dose, e.g. 7 bags can be supplied as 1 bag of 350 ml, which can be administered rapidly
(10 minutes). Transfusion services ordinarily supply platelets of appropriate ABO group specificity. The
treatment may be repeated over a period of days if the patient’s platelet level continues to decline or
remains critically low.

If there is manifest consumption of other coagulation factors (abnormal PTT and PR levels, fibrinogen level
<0.8g/L), administer fresh frozen plasma (FFP) or fresh dried plasma (FDP) at the rate of 10ml/kg body
mass for the first dose. The treatment may be repeated if the patient continues to bleed or if coagulation
factor levels remain markedly abnormal. As a general rule, 2-3 units of FFP or FDP should be administered
to augment coagulation factors for every 10 units of red cell concentrate given to the patient.

Fibrinogen is not available as a separate product, but apart from its administration in FFP and FDP, it
(and other factors) can also be administered in the form of cryoprecipitate. One bag of wet cryoprecipitate
contains about 250 mg of fibrinogen and a bottle of dried cryoprecipitate, called anti-haemophilia factor
(AHF), which is derived from a pool of 4-6 units of wet cryoprecipitate, contains approximately 1 g of
fibrinogen. About 1-2 g fibrinogen (10 bags of wet cryoprecipitate) may be administered as a first dose.

Prothrombin complex concentrate (PCC, factor IX complex, Proplex) may be indicated following liver
damage. It contains 200 units factor IX in a10 ml volume and a dose of 1 U/kg should increase the blood
level of the factor by approximately 1%. Vitamin K should also be administered.

Intravenous fluids

Plasma is used to replace coagulation factors, not merely for volume expansion, but it is expensive and
haemodynamic goals can be achieved with artificial colloids or even crystalloids. Iso-osmotic albumin solution
(4%) may be used for volume expansion. Although 20% albumin has been used to treat hypoproteinaemia
following liver damage in CCHF, it is considered better to use an enteral feed that provides sufficient
calories and protein according to body mass. If the gut is unavailable for enteral nutrition parenteral feeding
may be necessary.

Hypoglycaemia was thought to be of critical importance in a number of CCHF patients in South Africa and
blood glucose levels should be monitored carefully in severely ill patients.

Other therapy

There is no information on the effectiveness of steroids to allay the ‘cytokine storm’ underlying the DIC in

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 VHF patients, but there is some support for this approach from animal models. If used, the dose should
not exceed 200-300mg hydrocortisone daily. The use of non-steroidal anti-inflammatory drugs is not
recommended.

Antacids, painkillers, relaxants and tranquillisers are administered as indicated.

Antibiotic prophylaxis is generally not indicated, however many patients will have received antibiotics prior
to the diagnosis having been made. As with all patients in the ICU regular screening for colonization and
infection is necessary.

Counselling of patients and relatives is mandatory as this is a highly stressful situation.

6.2 Clinical pathology monitoring of VHF patients

Requirements

Hospitals which manage suspected or confirmed cases of VHF should have available the services of a
laboratory able to conduct the following tests:
• A minimum range of screening tests to eliminate non-VHF diseases:
- Full blood count.
- Examination of blood smears for parasites and bacteria.
- Blood cultures for septicaemia.
• Haematological and clinical chemistry tests to monitor treatment and progress of patients:
- Full blood counts (including platelet and haemoglobin values).
- Coagulation studies.
- Liver function tests.
- Blood glucose tests.
- Creatinine, urea, electrolyte determinations.
- Blood gases and pH determinations.
- Cross matching studies for transfusions.

Ideally the tests should be conducted by a small team of experienced volunteer technologists in a room
set aside for the purpose within an existing laboratory, but since the occurrence of VHF is sporadic the
expenditure to equip a dedicated unit is not justified. Consequently, the required tests are often conducted
within routine laboratory facilities temporarily set aside for the purpose as required.

Operational procedures

Technologists who conduct clinical pathology tests on specimens from VHF patients should be trained in the
donning, removal, and disposal of personal protective equipment (PPE), and entry and exit procedures from
infected areas, as described under isolation precautions for VHF patients (see section 6,3).

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Only volunteer team members should be present during the testing of specimens from suspected or confirmed
VHF patients, and as far as possible manipulation of specimens should be performed in biohazard laminar
flow safety cabinets (class IIA).

Duty registers should be kept, with staff subjected to the same monitoring as other medical personnel dealing
with VHF patients, and incidents constituting potential exposure to infection, including injuries and spillages,
should be dealt with as described in sections 6.4 and 7.

Decontamination of laboratory equipment including auto analyzers should follow standard operating
procedures developed from manufacturer’s instructions.

Decontamination of laboratory floors, walls and work surfaces, and disposal of waste materials, should follow
procedures described in section 6.4.

Specimens for monitoring of VHF patients should be preserved at least until the patient is discharged or a
diagnosis is established in a deceased patient, and should then be disposed of in a safe manner (autoclaved
or sent for incineration). However, specimens should be offered to the Special Pathogens Unit (SPU) at the
National Institute for Communicable Diseases (NICD) rather than destroyed, since much valuable information
is gained from the examination of serial samples from VHF patients.

Ideally a separate clotted blood sample should be taken daily from confirmed VHF patients for submission to
NICD, but these can be submitted together when the patient is discharged.

Specimens for monitoring of VHF patients should be preserved at least until the patient is discharged or a
diagnosis is established in a deceased patient, and should then be disposed of in a safe manner (autoclaved
or sent for incineration). However, specimens should be offered to the Special Pathogens Unit (SPU) at the
National Institute for Communicable Diseases (NICD) rather than destroyed, since much valuable information
is gained from the examination of serial samples from VHF patients.

Ideally a separate clotted blood sample should be taken daily from confirmed VHF patients for submission to
NICD, but these can be submitted together when the patient is discharged.

6.3 Isolation precautions (formerly known as barrier-nursing procedures)

Although the VHFs are seldom encountered, the consequences of being unprepared can be extremely
serious. All medical institutions should formulate and implement contingency plans for isolating and
managing VHF patients, even on a temporary basis. The aims should be to:
• Identify facilities and resources which can be utilized for isolating and managing VHF patients.
• Provide health care workers with training and instructions specific to their duties so that they are able
to act in an informed manner when suspected cases of VHF are encountered.
• Train all staff members to recognize potential cases of VHF, but ensure that critical assessment of such

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 cases is performed by experienced clinicians and infection control personnel.
• Train suitable volunteers in isolation precautions. Experience has shown that when VHF occurs in an
institution where there has been no prior discussion of VHFs and training in isolation precautions it may
be extremely difficult to obtain volunteers. Do not be caught unprepared.
• Ensure that infection control personnel monitor safety practices during isolation precautions and place
staff who are in contact with VHF patients or fomites under observation (see section 7.3).
• Establish proper channels of communication so that relevant members of staff at all levels are informed
promptly of the existence of a suspected case of VHF, or of the impending arrival at a hospital of such
a patient, and of all key developments in the handling of the case.
• Extend the system of communication to outside officials who need to be kept informed, such as
Communicable Disease Control officials of the national and provincial Departments of Health (see
section 7).
• Make provision for well-informed responses to enquiries from news media (see section 7).

Facilities

The minimum accommodation required for isolation precautions consists of one room in which the patient
may be isolated and an ante-room or adjacent room where staff can don and remove personal protective
equipment (PPE). Ideally, isolation units should have separate entrance and exit (‘clean and dirty’) channels,
and it is advantageous if the ante-room has a hand-basin and if ablution facilities are located in convenient
proximity to the patient’s room. The equipments and supplies required in the patient isolation room are listed
in Table 6.3 below. Since VHF patients are often in need of intensive care, the isolation unit may need to
consist of a cubicle or section of an ICU ward which can be closed off.

In addition to the patient room and ante-room there should be:

• An area suitable for a nursing station where staff wait when not in direct attendance on the patient.
• An area or room for storing supplies and equipment.
• A room or enclosed area for changing from street clothes into surgical theatre or equivalent clothing.
• An observation room/ward in which to place high risk contacts of VHF patients who become sick, i.e.
potential but unconfirmed secondary cases (such a facility is seldom required).
• A two-way communications system between the patient isolation room and the nursing station if
necessary.
• Purpose-built isolation facilities should theoretically have negative pressure air-conditioning systems
with high-efficiency particulate air (Hepa) filters on the exhaust ducts, but there are very few such units
in the world and these are at major research facilities. It was speculated that 2 nurses who did not have
direct contact with patients, but handled fomites such as bedpans, acquired Congo fever infection as a
result of virus passing through an air-conditioning system during a nosocomial outbreak in South Africa
in 1984, but there was no proof that this had occurred, and there is no evidence that air-conditioning
systems constituted a hazard in the isolation of a further 200 VHF patients in South Africa, or in
large outbreaks managed by international response teams elsewhere in Africa. Hospitals encounter
suspected VHF patients so infrequently that it is not feasible to build dedicated patient isolation units
and keep them vacant on standby. Instead, it is necessary to identify suitable facilities which remain in

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 Table 5: Equipment and supplies required in the patient isolation room and ante-room

Equipment that should not be removed unless they are Personal protective equipment
decontaminated (PPE)
Sphygmanometer. Theatre tops and trousers or equivalent
Stethoscope. cover-all garments (also available in
disposable form).
Thermometers.
Urinal and bedpan.
Gowns (long-sleeved, waterproof,
Bucket, mop and disposable cleaning cloths or paper towels. disposable type).
Fresh 500 and 5000 ppm chlorine disinfectant solutions daily (see 6.4); volumes
depend on demand. Vinyl or rubber aprons.
Clock with second hand.
Balaclava-type caps (disposable).
Drip stand
Urine testing and measuring equipment.
Items such as a bed, locker, ventilator, and monitor, are placed in the isolation room for
patients being received from outside of the hospital, or are transferred from the original Face masks, eg N95 masks.
ward together with patients being moved into isolation within the same hospital.
Masking or autoclave tape. Goggles, plastic.
Ballpens.
Felt-tip marker pens. Goggles may be replaced by clear
Patient record forms. acrylic visors, or disposable visors, or
Specimen containers, labels and packaging. combined visor-masks.
Disposable syringes and needles.
Swabs. Latex and non-allergenic surgical gloves.
Adhesive bandage, e.g. Elastoplast.
Scissors.
Canvas or similar slip-on shoes.
Refuse bags and bins.
Overshoes (disposable) or stout plastic
Plastic autoclave bags.
bags.
Plastic cable ties for sealing bags 12 (obtainable from electrical/hardware stores).
Small, clear plastic bags for removal of specimens or other small items from the
isolation room.
Biohazard labels
Disposable eating utensils.
Desk, chairs
Restricted entry and hazard warning signs.
Register to record entry and exit of persons with authorized access to the isolation
unit.

Much of the PPE is available in disposable plastic or paper form at all hospitals and clinics. Up to 25 changes of
protective clothing may be required per day in nursing a patient during the critical phase of VHF illness (not all
patients become severely ill or exhibit bleeding tendencies). Some hospitals utilize mended and condemned
linen and theatre clothes for nursing VHF patients, but dye the items an obvious colour to help ensure that
they are disposed of safely. Ideally, hospitals should keep stocks of the essential items in readiness, but this
involves dedication of funds and secure storage space, plus rotation of perishable items. Alternatively, stocks
should be secured immediately an emergency arises. Formidable epidemic disease packs (FED packs)
containing virtually all of the above PPE items are available commercially, and customized packs can be
prepared to order or within the hospital.

Safety equipment

It is notable that international teams operating under the auspices of the World Health Organization to control

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outbreaks of Marburg and Ebola haemorrhagic fevers in Africa use only standard PPE items specified above.
Almost all VHF patients in South Africa have been nursed without special safety equipment, and all nosocomial
infections occurred before the patients were placed under conditions of isolation precautions.

In the past, some hospitals in South Africa acquired special safety equipment for protection of staff against
nosocomial infection, ranging from containment bed isolators, full-face respirators (gas masks) to battery-
operated positive-pressure ventilated respirators (‘pappers’). There are disadvantages associated with each
of these items: bed isolators are very expensive and occupy a large floor space; gas masks are tiring to
use and tend to become fogged, thus reducing visibility and efficiency; pappers require expensive semi-
disposable hoods and interfere with the use of stethoscopes.

Nevertheless, the use of pappers may be warranted for particularly hazardous procedures, such as intubation
of VHF patients under intensive care. Hoods may be re-used by the same staff member for successive entries
into the patient isolation room provided they are disinfected on exit from the isolation room as described
below (they should be marked with the name of the user). Power supply points will be required in the ante-
room for re-charging batteries, plus a rack or coat hooks for hanging respirators and hoods when not in use.

Personnel

Ideally, specifically trained, volunteer staff should be used for nursing VHF patients, and personnel who were
in contact with the VHF patient/s before isolation precautions were implemented should be utilized first to limit
potential exposure of further members of staff. Select persons of calm disposition able to cope with the stress
of nursing VHF patients under strict isolation precautions.

Nosocomial infections can almost invariably be traced to fundamental lapses in technique, such as needle-
sticks, against which most safety equipment cannot protect. Fatigue causes mistakes and hence adequate
numbers of staff should be delegated to nursing patients under conditions of strict isolation precautions
without seriously depleting the rest of the hospital or unnecessarily exposing too many individuals to VHF. If
the nursing load is too heavy, as when multiple patients are involved, it may be necessary to suspend some
or all-routine functions of the hospital. Counselling of staff (plus patients and families) should be offered to
alleviate stress.

Shifts should be limited to a maximum of 8 hours (6 hours are preferable) to ensure a high degree of efficiency.
Intensive nursing of critically ill VHF patients may require 3-5 persons per shift, 1-2 of whom are in the
patient’s room on a 1-2 hourly rotation. Low profile nursing of moderately ill patients requires less staff and
often it is unnecessary to maintain a constant presence in the patient’s room.

In addition to the staff members who are directly in attendance on the patient, one member of the nursing
or administrative staff should remain outside of the isolation area to control communications, logistics and
access to the isolation suite. In large hospitals it may be necessary to use security officers to control access
to the isolation suite.

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Domestic and any other staff who have not been specifically instructed in isolation precautions must be
excluded from the isolation suite.

All medical and auxiliary staff (ambulance and laboratory personnel) who come into contact with a suspected
or confirmed VHF patient or fomites, either before or after the institution of isolation precautions, must be
placed under observation (see section 7). This should be done formally but the precautionary nature of the
measure should be explained carefully.

Incidents constituting possible exposure to infection, e.g. needle sticks or other direct contact of skin with
patient’s blood or body fluids, must be recorded and promptly brought to the attention of the hospital’s infection
control team to decide on any action to be taken (see section 7).

Baseline blood counts plus serum transaminase tests may be performed for persons who have had contact
with a VHF patient or fomites, and serum samples should be kept frozen for later use if suspected infection
occurs. However, this should be limited to persons with definite exposure to infection such as a needle-stick
with known infected blood. Indiscriminate bleeding of contacts generates undue concern and unreasonable
demands from people who have not had genuine exposure to infection.

Placing a patient into isolation

Explain to the patient and family that isolation precautions are being instituted and make an effort to reassure
them. The donning of protective clothing by medical personnel can have a demoralizing effect on lay people.

Establish from the clinician in charge whether or not the patient’s immediate family will be permitted to visit
the patient (under supervision and with proper protective clothing). Inform the family accordingly and arrange
for instruction in correct use of protective clothing.

Ensure that all staff are informed that the patient is being placed into isolation, institute control over access to
the isolation suite and display appropriate warning notices. Henceforth only specifically authorized personnel
may have access to the patient and all staff must wear protective clothing when tending the patient.

The patient is transferred to the isolation room on his/her bed, and all other items of equipment required from
the original ward (e.g. locker, ventilator, monitor, etc.) are moved with the patient. The procedure for receiving
VHF patients from outside the hospital is described in section 7.

All non-essential items, including the patient’s records, are left in the original ward and are decontaminated
in the prescribed manner by personnel wearing protective clothing (see section 6.4). New patient records
are started and kept outside of the isolation room.

All other patients who were in the original ward with the VHF patient are transferred, preferably to a single other
ward, so that the original ward can be decontaminated (see section 6.4). Sometimes it is more convenient to
leave the VHF patient in the original ward and convert it into an isolation room.

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Ensure that the infection control team prepares a register of all persons deemed to have had contact with the
VHF patient/s and places contacts under observation (see section 7.3).

Ensure that a duty register is kept of all staff shifts and visits to the patient, to ensure traceability of contact
with the patient.

Dressing for entering the patient isolation room

In a change-room or other suitable area close to the entrance to the isolation suite, staff remove all jewellery
and replace their street clothes with surgical theatre tops and trousers, or equivalent cover-all garments
(washable fabric or disposable), plus canvas or similar slip-on shoes. These clothes are worn for the duration
of the work shift and are used to move around in the vicinity of the isolation suite, but an extra layer of
protective clothing is donned in the ante-room for entry into the patient isolation room:
• Long-sleeved, waterproof, disposable gown.
• Vinyl or rubber apron if more than light duties are involved, e.g. bleeding patients.
• Two pairs of latex surgical gloves, one worn over the other - the cuffs of the outer pair of gloves should
be pulled over the cuffs of the gown and taped in place with masking tape around the wrist.
• Disposable balaclava-type cap.
• Disposable face-mask, e.g. N95 – cannot be used with facial hair (beards).
• Goggles or acrylic visor, or disposable visor.
• A disposable combination visor-face mask can replace a separate mask and goggles or visor.
• Alternatively, a positive-pressure ventilated respirator (papper) with hood could replace the balaclava,
face-mask and goggles or visor.
• Two pairs of overshoes, one over the other, or heavy duty plastic bags taped to the trouser legs, or
waterproof boots.

Needles, other sharp objects, patient’s blood, blood-contaminated discharges and equipment soiled with
blood constitute the greatest danger and must be handled with extreme care. Gloved hands contaminated
with patient’s blood or discharges should be dipped into 500 ppm chlorine disinfectant solution (see section
6.4) kept in the isolation room. Gloves must be checked frequently for tears or punctures and if the patient
bleeds profusely, both inner and outer gloves must be changed hourly and the hands washed thoroughly in
soap and water or surgical scrub disinfectant.

Procedure for leaving the patient isolation room

The procedure for leaving the isolation room must be followed strictly to prevent contamination of personnel
and the environment. Double refuse or autoclave bags (heavy duty), which are used to receive discarded
protective apparel, are placed one inside the other in a bin or holder in the ante-room with 20-30 cm of the
top of the bags folded back over the rim of the bin or holder to form a clean margin when the bag is sealed.
The bin is placed close to the door leading from the patient isolation room.

On leaving the patient isolation room, the outer overshoes are removed and placed in the disposal bag.

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Waterproof overshoes or boots may be dipped into a bucket/tray of 500 ppm chlorine disinfectant (see section
6.4) before being removed. The outer gloves are dipped or washed in 500 ppm chlorine disinfectant (see
section 6.4), peeled off and discarded into the disposal bag. The inner gloves are used to remove the other
items of protective wear and to place them in the disposal bag as follows:
• Goggles or acrylic visors are removed and placed in 500 ppm chlorine disinfectant (see section 6.4).
• Disposable combination visor-masks are discarded into the disposal bag.
• If a positive-pressure respirator is being worn, an assistant in the ante-room swabs or sprays the outer
surface of the hood with 500 ppm chlorine disinfectant (see section 6.4) and with gloved hands helps to
remove the respirator; the swabbed hood is hung on a hook or rack to dry; the respirator itself is hung or
placed on a suitable surface and connected to a battery charger. Respirator hoods are marked with the
names of individual members of the team for re-use, and are discarded for incineration or safe disposal
when no longer required.
Facemasks and balaclava caps are removed and placed in the disposal bag.
• Next, aprons and gowns are removed and folded or rolled in the process so that outside surfaces are
on the inside and they are placed in the disposal bag.
• The inner pair of overshoes and finally the inner gloves are removed and placed in the disposal bag,
and the hands are washed thoroughly with soap and water or surgical scrub disinfectant (use of ethyl
or isopropyl alcohol is not recommended for disinfection of the hands in nursing VHF patients).
• The inner and outer top rims of the disposal bags are sprayed with 500 ppm chlorine disinfectant
(section 6.4) and sealed by a gloved assistant, conveniently with plastic cable-ties obtainable from
electrical or hardware stores, or with adhesive tape. The double bags are sealed into a third bag, or
several layers of bags if necessary to prevent leakage. It is useful if the outer bag is colour-coded,
e.g. red, to indicate that it contains biohazardous material due for incineration. However, red bags are
commonly used for waste in hospitals.
• The outer bag is labeled with biohazard stickers and sent for incineration under supervision, or sealed
into the container of a commercial biohazardous materials disposal contractor, e.g. Sanumed®.
• Surgical theatre clothes or equivalent cover-all garments and footwear are removed in the outer change
room and discarded into laundry or disposal containers as appropriate, and staff don their street clothes.
Preferably, staff should be able to take a shower bath before leaving the isolation area.

Procedures for dealing with potentially hazardous incidents

All incidents constituting possible exposure to infection, such as needle stick injuries and splashing with
patient’s body fluids must be recorded and reported to infection control staff to decide on appropriate action,
and an Employer’s Report of an Accident Form (Compensation for Occupational Injuries and Diseases Act,
1993) must be completed and submitted.

First aid procedures should be applied as considered necessary, eg bleeding of needle stick or sharp
instrument injury sites should be encouraged and wounds bathed in copious 500 ppm chlorine disinfectant
(see 6.4).

Infection control staff in consultation with senior clinicians and management should decide whether staff

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members potentially exposed to infection should be placed in quarantine (section 7), subjected to prophylactic
treatment (section 6.1), or simply kept under observation (section 7).

Patient care facilities should be subjected to routine disinfection, but overt spillages of hazardous materials
should be dealt with as they arise (section 6.4).

Discharge of patients

Provided they are well, Congo fever, Rift Valley fever and other arbovirus disease patients can be removed
from strict isolation precautions, or even discharged from hospital, two weeks after onset of illness, but they
should remain under supervision and refrain from strenuous activity for a month or more, depending on their
progress. Meningism, encephalitis and ocular lesions can occur as late complications of Rift Valley fever.

Patients with a diagnosis of any of the other African haemorrhagic fevers should be nursed in isolation for at
least 3 weeks after onset of illness. Sexual transmission of Marburg virus in semen has been recorded two
months after recovery of the patient and the same could probably occur with Ebola virus. Excretion of Lassa
fever virus in urine has been observed to occur over a period of a few weeks, and hence the discharge of
Lassa fever or Lujo virus patients from hospital should be made consequent upon failure to isolate virus or
to detect viral nucleic acid by RT-PCR in three consecutive urine samples collected on separate days. The
same would apply to haemorrhagic fever with renal syndrome (HFRS) patients, but culture of the viruses is
difficult and erratic.

Recovery from VHF may be marked by prolonged convalescence and it is advisable that patients should
be kept under casual surveillance for about 3 months. They should be warned of the possibilities of their
transmitting infection through intimate contact during this time.

If convenient, serum samples from recovered patients should be sent for monitoring of antibody levels at
intervals after recovery as opportunity arises; useful diagnostic information on the duration of IgM and IgG
responses is accumulated in this manner. Patients should be approached about the possibility of donating
immune plasma once they are fully recovered, for preparation of control reagents for diagnostic tests, or for
possible therapeutic use. Offers to donate plasma can be discussed with the Special Pathogens Unit at NICD
(telephone numbers 011 386 6339, 082 903 9131, 082 908 8042 and 082 908 8045).

6.4 Disinfectants and decontamination

The use of disinfectants is not a substitute for sterilization by physical means, especially heat as in
autoclaving or incineration. However, there are many situations where it is necessary to resort to the use of
disinfectants, and the present discussion is limited to requirements for managing VHF patients. The use of
brand names does not imply recommendation of a product to the exclusion of similar preparations. It should
be remembered that mechanical cleansing is an integral part of proper disinfection: excess organic matter
rapidly reduces the efficacy of disinfectants.

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Choice of general disinfectant
Inorganic chlorine, in the form of diluted household bleach, has been used as the disinfectant of choice in
controlling outbreaks of VHF in Africa because it is effective, relatively inexpensive and readily available.
However, inorganic chlorine corrodes metals and tends to degrade fabrics. Brand-name household
bleaches contain 5% sodium hypochlorite and are diluted as follows for use:

A 10% aqueous solution of household bleach (one part bleach plus 9 parts water) yields 0.5%
hypochlorite, or approximately 5000 ppm chlorine, and is used for disinfecting overt spillages of
contaminated materials, excreta (organic wastes) and surfaces of corpses.

A 1:100 aqueous solution of household bleach (one part bleach plus 99 parts water, or 1 part of 10%
diluted bleach plus 9 parts of water) yields 0.05% hypochlorite, or approximately 500 ppm chlorine, and
is used for disinfecting gloved hands, walls and floors without overt spillages of contaminated materials,
clothing, bedding, equipment and instruments, and the outer surfaces of sealed plastic bags containing
infected or contaminated materials.

One or two crystals of potassium permanganate (Condy’s crystrals) can be added to undiluted
household bleach to impart a pink colour to the diluted solutions of disinfectant for easy identification.
Fresh stocks of diluted disinfectant should be prepared daily.

‘Organic’ chlorine formulations which contain a detergent, an anti-corrosive agent and chlorine incorporated
in or complexed to organic molecules (chloro-cyanurates and chloramines) offer clear advantages over
inorganic hypochlorite. A dry granular preparation of this type is sold in South Africa as Biocide D (6g granules
per sachet), or as Biocide D Extra (30g granules per sachet) (Johnson Diversey, Germiston):

Disinfectant solutions should be clearly labelled with the concentration of active ingredient and date of
preparation.

Choice of hand disinfectant

Gloved hands are generally rinsed in 500 ppm chlorine, and although this can also be used to rinse bare
hands, it is recommended that when surgical gloves are removed after nursing or transportation of VHF
patients, or performance of clinical pathology tests, the hands should be thoroughly washed with soap and
water, or with a surgical scrub preparation. Ethyl or isopropyl alcohol preparations are not recommended
for disinfection of the hands in managing VHF patients, although they can be used as skin disinfectants for
injection of patients.

Decontamination and disposal of hazardous items

A specific individual in each nursing shift, or ambulance crew transporting a VHF patient, should be responsible
for supervising decontamination and disposal of biohazardous items. All items leaving the isolation unit
(patient’s room and anteroom, or ambulance) should be enclosed in double layer autoclave bags (or more

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layers if necessary to prevent leakage) and sealed with cable ties or adhesive tape. The outer surface should
be labelled with biohazard stickers and swabbed with 500 ppm chlorine disinfectant.

Twenty sachets of Biocide D Extra (600g) dissolved in 10 litres of water yields 0.5% hypochlorite, or
approximately 5000 ppm chlorine, and is used for disinfecting overt spillages of contaminated materials,
excreta (organic wastes) and surfaces of corpses.

Two sachets of Biocide D Extra (60g) dissolved in 10 litres of water yields 0.05% hypochlorite, or approximately
500 ppm chlorine, and is used for disinfecting gloved hands, walls and floors without overt spillages of
contaminated materials, clothing, bedding, equipment and instruments, and the outer surfaces of sealed
plastic bags containing infected or contaminated materials.

Fresh solutions should be prepared daily.

‘Organic’ chlorine formulations which contain a detergent, an anti-corrosive agent and chlorine incorporated
in or complexed to organic molecules (chloro-cyanurates and chloramines) offer clear advantages over
inorganic hypochlorite. A dry granular preparation of this type is sold in South Africa as Biocide D (6g granules
per sachet), or as Biocide D Extra (30g granules per sachet) (Johnson Diversey, Germiston):

Disinfectant solutions should be clearly labelled with the concentration of active ingredient and date of
preparation.

Choice of hand disinfectant

Gloved hands are generally rinsed in 500 ppm chlorine, and although this can also be used to rinse bare
hands, it is recommended that when surgical gloves are removed after nursing or transportation of VHF
patients, or performance of clinical pathology tests, the hands should be thoroughly washed with soap and
water, or with a surgical scrub preparation. Ethyl or isopropyl alcohol preparations are not recommended
for disinfection of the hands in managing VHF patients, although they can be used as skin disinfectants for
injection of patients.

Decontamination and disposal of hazardous items

A specific individual in each nursing shift, or ambulance crew transporting a VHF patient, should be responsible
for supervising decontamination and disposal of biohazardous items. All items leaving the isolation unit
(patient’s room and anteroom, or ambulance) should be enclosed in double layer autoclave bags (or more
layers if necessary to prevent leakage) and sealed with cable ties or adhesive tape. The outer surface should
be labelled with biohazard stickers and swabbed with 500 ppm chlorine disinfectant.

Disposable items should be sent for incineration under supervision and re-useable items for autoclaving.
Crockery and cutlery used for feeding VHF patients should ideally be of the disposable type and incinerated
along with food wastes.

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Bedpans and other containers with patient secretions, excretions and other wastes such as vomitus and
blood, should be flooded with copious 5000 ppm chlorine disinfectant, left for at least 30 minutes, and sealed
into adequate layers of leak-proof autoclave bags or other secure secondary containers (e.g. stainless steel
container). The outer surfaces of the bags or containers should be swabbed with 500 ppm chlorine disinfectant,
labelled with biohazard stickers and the items removed for autoclaving and cleaning. Autoclaved wastes can
be flushed into municipal sewers. After flushing, bedpans are cleaned with 500 ppm chlorine disinfectant.
Thoroughly disinfected wastes (prolonged exposure to copious disinfectant) can also be discarded into
sealed disposal pits, or buried.

It is convenient to use chemical toilets instead of bed pans for ambulant patients.

Vinyl, rubber and other items which are degraded by autoclaving could be discarded and incinerated, or
subjected to prolonged immersion in 500 ppm chlorine disinfectant.

The hoods of battery-operated positive-pressure ventilated respirators (‘pappers’) are discarded for
incineration at the termination of patient treatment, and the respirators are swabbed with 500 ppm chlorine
disinfectant, and sealed into labelled bags and sent for gaseous sterilization.

Hypodermic and intravenous needles should be used with great care, discarded into rigid-walled disposal
containers, flooded with a 5000 ppm chlorine disinfectant (see 6.4), sealed into leak-proof bags, labelled and
sent for incineration.

Used linen and cloth items of protective wear should be sealed into labelled bags and autoclaved before
laundering, but consideration should be given to incinerating grossly contaminated items such as bloodstained
mattresses and pillows. Items, which are not visibly soiled, could be soaked in 500 ppm chlorine disinfectant
for 30 minutes before laundering. Persons laundering cloth protective apparel or bedding used for VHF
patients should don personal protective equipment (PPE) as described for isolation precautions (see section
6.3).
Vomitus, blood and other overt spillages on floors and similar impervious surfaces should be flooded with
5000 ppm chlorine disinfectant, covered with paper towels and left for 30 minutes before removal.

Floors of VHF patient isolation units should be mopped and drains flushed with 500 ppm chlorine disinfectant
daily, or whenever there is spillage of potentially contaminated material. Rinsed mops should be soaked
in 500 ppm chlorine disinfectant for 30 minutes. At the termination of patient treatment the walls and all
impervious surfaces in isolation units (lockers and tables) should be swabbed in addition to the disinfection of
floors and drains. The same procedures should be applied to mortuaries and laboratories handling corpses
or samples of suspected or confirmed VHF patients.

Patient records, which have been kept in an infected environment, can be bagged and autoclaved, or the
information preserved by other means, e.g. copied from records, taped to a window or glass partition, or
transmitted via telephone.

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6.5 Disposal of corpses

Corpses of suspected VHF patients may be processed for immediate disposal if an etiological diagnosis has
been confirmed. If a diagnosis has not been established, then in terms of the Health Act 61 of 2003 certain
medical practitioners are empowered to authorize the performance of an autopsy to determine the cause of
death, as described in section 7 of this document. Usually the autopsy procedures are limited to collecting
blood by cardiac puncture and taking liver samples with biopsy needles.

After the autopsy specimens have been taken, the corpse may be held under refrigeration in a mortuary if
the facilities exist, while laboratory investigations to eliminate VHF proceed. This usually takes a week, and
if a diagnosis of VHF is eliminated, it may be deemed safe and/or necessary to proceed with a full autopsy
to establish the cause of death.

For disposal, corpses are washed with 5000 ppm chlorine disinfectant (see section 6.4 above). Orifices
are plugged with gauze and puncture sites are taped or sealed (Opsite®, S & N Pharmaceuticals Pty Ltd).
The corpse is enclosed in an impervious body bag and sealed (it is advantageous if the body bag has an
air-valve). The attendants change protective clothing, swab the body bag with fresh disinfectant and seal
the corpse into a second impervious body bag. After disinfection of the outer body bag, the corpse can be
removed for storage in a mortuary or placed in a coffin for disposal. If impervious body bags are not available,
adequate layers of stout plastic shrouds may be used.

The shrouded corpse should be placed in a coffin packed with absorbent material (sawdust) which is moistened
with 5000 ppm chlorine disinfectant (see 6.4). The coffin should be sealed and wiped with 500 ppm chlorine
disinfectant (see 6.4). The corpse should be cremated or buried under the supervision of a representative of
the provincial Department of Health and Hospital Services, more specifically the office of the Coordinator of
Communicable Disease Control.

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 7. Notification And Control Of Outbreaks Of VHF

7.1 Transfer of VHF patients

7.1.1 Arranging transfer of VHF patients

Reasons for and against transfer of VHF patients

Patients are often transferred through one or more hospitals before VHF is suspected. However, once VHF
is suspected or confirmed, the following points must be taken into consideration:

Indications for transfer of VHF patients

The most important reason for transferring a patient is the need for better medical care. Another valid
reason is to achieve greater safety in isolation and nursing of patients. Thus, there are stronger grounds for
moving moderate or high risk patients to better facilities, but low risk patients are easier to move safely (see
section 5 for discussion of risk categories). The existence of a conveniently-located referral centre which
has been specifically designated and equipped to receive VHF patients, is an obvious incentive to transfer
patients.

Contraindications to the transfer of VHF patients

Patients should not be moved when their condition does not allow this to be achieved safely: the process
may unduly threaten the life of the patient, or involve too great a risk of spreading infection. It is inadvisable to
move patients when there appears to be a continuing outbreak of infection, as in common source outbreaks
in abattoirs or on farms, or when there has been definite exposure of contacts (as in nosocomial needle
sticks), or when secondary cases have already become manifest. The inference is that further cases may
arise and that transfer of patients merely results in creating two or more potential centres of infection where
contacts have to be placed under observation. Under certain circumstances, therefore, it is better to second
trained staff and the required equipment to the primary hospital, than it is to move patients.

Reaching a decision on transfer of VHF patients

Decisions are reached with greatest facility where a framework for consultation has been organized as a
matter of preparedness. Thus, a pre-arranged panel within the primary hospital should perform the initial
clinical evaluation and decide whether there are indications for seeking transfer of patients. The panel
should include clinicians, infection control and management representatives. Advice can be sought from
the medical officer on duty at the National Institute for Communicable Diseases (NICD) (NICD Hotline 082
883 9920).

Once it has been decided to seek transfer of a patient, it should only be necessary to contact one person
per telephone at the referral hospital. This person should be authorized to take decisions on accepting
transfer of VHF patients, or be able to obtain decisions rapidly. Experience has shown that decisions can
be reached with suitable expediency (see requirements for a VHF referral centre on the following pages).

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 Arrangements for transporting the patient should be made at the same time (see 7.1.2 and 7.1.3 below).

If the primary hospital does not have information available on provincial policy with regard to
referral of VHF patients, or contact details for a referral hospital, information can be sought from
the provincial Coordinator of Communicable Disease Control (see section 7.2), who must in any
event be informed of transfers of VHF patients.

7.1.2 Non-ambulance transport of low risk VHF patients

Before VHF is diagnosed, patients are usually transported to doctors’ rooms or hospital without special
precautions. Once VHF is suspected, patients should not be transported without specific precautions to
prevent spread of infection. However, there is generally room for judicious improvisation in transporting
VHF patients in the early stages of disease. For instance, when febrile illness first occurs in a known
VHF contact, there appears to be no valid objection to the patient being taken to hospital in the vehicle
of a relative with whom the patient has already had close contact. The safety of those in attendance
should nevertheless remain a prime consideration and patients who are severely ill, or who are vomiting
or manifesting haemorrhagic signs, should only be transported by an ambulance crew using appropriate
personal protective equipment (see 7.1.3 below).

7.1.3 Transport of VHF patients by ambulance

There appear to be no strong reasons for the transportation of suspected or confirmed VHF patients by
air within South Africa, and this has not occurred during the past decade.

Administrative considerations

As recommended for hospitals, ambulance and emergency medical services are advised to ensure
that staff is trained in the recognition of VHFs, assessment of the condition of patients, and in essential
isolation precautions for safe transportation of patients (see 6.3). This applies particularly, but not
exclusively, to ambulance crews, which provide a service for designated VHF referral hospitals.
Ambulance crews tasked with the transport of VHF patients at referral centres should ideally be
composed of volunteer personnel, and be contactable through a designated individual to whom all
requests for transport of VHF patients should be channelled.

Equipment

Ambulance and emergency medical services should keep stocks of personal protective equipment (PPE),
most conveniently in the form of formidable epidemic disease (FED) packs, each containing:
• Disposable gown 1
• Disposable balaclava type cap 1
• Dust goggles 1 (alternatively a clear acrylic visor or disposable visor)
• Disposable plastic aprons 2

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 • Theatre masks, moulded 2
• Surgical gloves 2 pairs
• Overshoes 2 pairs
In addition, there should be decontamination (DECON) packs each containing:
• Plastic autoclave bags (preferably red) 10
• Sharps disposal container
• Biocide D Extra or equivalent disinfectant, 50 sachets
• Biohazard labels
• Felt tip marker pen
• Masking tape 1 roll
• Plastic cable ties for sealing bags 12 (obtainable from electrical/hardware stores)
• Paper towels 4 rolls
• 10 litre plastic bucket (it is a good idea to mark 1 litre graduations on the bucket)

Ambulances despatched to transport suspected or confirmed VHF patients should carry 10 FED and 2
DECON packs. Although the ambulance should be stripped of non-essential equipment, it should carry
a suction unit, a complete oxygen supply unit and the standard range of equipment for management of
patients. Items could be sealed into plastic bags with adhesive tape and opened only if required.

Battery-operated positive-pressure ventilated respirators (‘pappers’) (e.g. Racal ‘Dust Master’, Delta Health
& Safety, Kempton Park) with disposable hoods could replace the balaclava, face mask, goggles or visor in
high risk situations. Two pappers are required per ambulance crew, and they must be maintained in working
order with batteries charged at the base from which the ambulance operates. Pappers can generally be
used for up to 8 hours with fully charged batteries. The disposable hoods are relatively expensive.

Operational procedures for the transportation of VHF patients by ambulance

A minimum ambulance crew of 3 members is required for the transportation of a VHF patient. The clinician
requesting transport should advise the ambulance team of the condition of the VHF patient and of the
appropriate protective measures to be taken, eg:
• Conscious patient, no vomiting, no active visible haemorrhage, in full control of urinary bladder and
bowel function - ambulance crew to use protective clothing as contained in FED packs; and
• Patient with disturbed level of consciousness, vomiting, possible haemorrhages or pulmonary
involvement, not in control of urinary bladder or bowel functions - the use of battery-operated positive-
pressure ventilated respirators (‘pappers’) with hoods in place of the balaclava cap, masks and goggles
or visors is advisable, particularly if there is to be nebulization, suctioning, intubation and manual
ventilation of the patient.

The donning and removal of PPE and the use of pappers for safe transport of VHF patients should follow the
routines described for isolation precautions for VHF patients in hospitals, with disposal of soiled items into
double autoclave bags, sealed with cable ties or adhesive tape and labelled with biohazard stickers (see
sections 6.3; 6.4). Re-usable items should be bagged separately from disposable items. Sharp instruments,

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particularly needles, should be used with great care and disposed of into appropriate sharps disposal
containers.

On arrival at the location of the patient, the 3 crew members should all don protective clothing, but the driver
should avoid contact with the patient and act as a liaison between the other 2 crew members and local
hospital staff to ensure safe transfer of the patient into the ambulance.

Five of the FED packs should be carried in the driver’s compartment and these could be made available to
the personnel at the referring hospital if necessary for use in transferring the patient and in decontaminating
afterwards (information on hospital decontamination procedures can be found in section 6.4 of this
document).

Before transferring the patient, the crew should re-assess his/her condition and if necessary consult the
clinical team at the referral hospital per telephone if there has been marked deterioration.

Patients must be brought by wheeled bed or hospital trolley to the ward entrance and then transferred to
the ambulance stretcher, to minimize further contamination of the hospital, and passages should be kept
clear during transit of the patient. The receiving hospital should be given an estimated time of arrival by
the ambulance crew, and the patient should be taken by shortest route to the appropriate ward through
passages which are kept clear during the transit.

Decontamination of the ambulance and disposal of hazardous items

Crew members decontaminating ambulances should don PPE as contained in FED packs. During or after
transport of a VHF patient, vomitus, blood and other spillages should be flooded with disinfectant at a
concentration of 5000 ppm available chlorine (20x30g sachets of Biocide D Extra/10L water - see section
6.4), and covered with paper towels for at least 30 minutes before being wiped up. Overt spillages should
never be sprayed with disinfectant.

Containers with secretions, excretions and other wastes such as vomitus and blood, should be flooded with
copious chlorine disinfectant at a concentration of 5000 ppm (20x30g sachets of Biocide D Extra/10L water
- see section 6.4) for at least 30 minutes.

All items leaving the ambulance should be enclosed and sealed in adequate layers of autoclave bags to
prevent leakage. The outer surfaces of the bags should be wiped with chlorine disinfectant at a concentration
of 500 ppm (2x30g sachets of Biocide D Extra/10L water - see section 6.4) and labelled to indicate that the
bags contain biohazardous material. Disposable items should be sent for incineration under supervision
and re-usable items sent for autoclaving.

The ambulance interior should be swabbed, including fittings, with chlorine disinfectant at a concentration
of 500 ppm (2x30g sachets of Biocide D Extra/10L water - see section 6.4). It is convenient to dispense 500
ppm chlorine disinfectant from rigid-walled plastic spray bottles for cleaning surfaces which are not visibly

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 contaminated.

Crew members who decontaminate ambulances should remove their PPE as described for isolation
precautions during nursing of VHF patients in hospitals, with disposal of soiled items into double autoclave
bags, sealed with cable ties or adhesive tape and labelled with biohazard stickers (see sections 6,3; 6.4).

7.1.4 Importation of VHF patients and transportation by air

South Africa accepted transfer of an American citizen with suspected Ebola fever from Zaire (DRC) in 1976
(laboratory tests proved to be negative), but since then it appears that no country has granted permission
for the intentional importation of suspected or known cases of VHF, although technically countries could
not exclude their own citizens. However, there have been many unwitting importations of VHF patients
worldwide, sometimes resulting in the occurrence of fatal nosocomial infections, also in South Africa.

As with other countries, South African regulations pertaining to the importation of suspected or known
cases of VHF are intended to give effect to the International Health Regulations of 2005 (IHR 2005), which
aim to control national and international spread of contagious diseases.

The importation of patients into South Africa by air occurs in two ways:
Intentional importation of patients – patients who are referred for medical attention are often assisted by
evacuation companies which operate their own air ambulance services, but which may utilize scheduled
commercial airline flights for ambulant patients with non-contagious conditions.

• It is the responsibility of the aeromedical assistance company to ensure that visas are obtained for
patients if necessary from the Department of Home Affairs.
• If the patient’s condition is considered to be non-contagious (eg traumatic, surgical, obstetric or
neoplastic) the pilot of the medical evacuation flight need only submit a general declaration
(GENDEC) by facsimile to the Port Health Officer (PHO) at the port of intended entry, most often
O.R.Tambo or Lanseria airports.
• If a contagious disease (or suspected VHF) is involved, the aeromedical assistance company (pilot)
must obtain prior clearance for importation of the patient through submission of a duly completed
request form AC1 by facsimile to the PHO at the intended port of entry. The PHO must obtain
expeditious clearance from the provincial Directorate of Health and Hospital Services (specifically
the office of the Coordinator of Communicable Disease Control), which may in turn consult, or at
least must notify, the national Ministry of Health. In practice, the referring clinicians in the country of
origin of the patient, the aero-medical assistance company, as well as health authorities and the
referral hospital within South Africa, often seek advice from the medical officer on duty at the NICD
(NICD Hotline 082 883 9920) in instances where VHF may be involved.
• The PHO informs the pilot or person who made the request of the decision to permit or decline
permission for importation of the patient by facsimile of form PH1, with a reference number. In
general, requests for importation of suspected or known cases of VHF will be declined unless there
are exceptional circumstances, eg. a South African citizen is involved.

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Aeromedical assistance companies, and hospitals which accept patients from abroad, are well advised
to comply strictly with the legal requirements for their own safety and the safety of others, as well as to
avoid liability to prosecution or litigation. Aeromedical assistance companies have the same obligations as
hospitals and ambulance services to ensure that staff is trained in the recognition of VHFs, assessment of
the condition of patients, and in essential isolation precautions for safe transportation of patients (see 6.3).

Air ambulances should have available the same safety equipment as recommended for road ambulances
(e.g. PPE FED packs and DECON packs, plus pappers) (section 7.1.3 above), and apply the same operational
principles in transporting patients as described for ambulances. The use of pappers is particularly advisable
if there is to be nebulization, suctioning, intubation and manual ventilation of potential VHF patients within
the confined space of an air ambulance.

Although most instances of intentional importation of potential cases of VHF have involved Gauteng airports
commonly utilized for medical evacuation of patients from tropical Africa, the increasing tourist trade and
the institution of direct flights to remote destinations implies that vigilance should be maintained at all South
African airports. Management of a suspected VHF patient on arrival at the port of entry is discussed
below (see procedure below on the arrival of a flight with a suspected or known VHF patient).

Unintentional importation of VHF patients - patients who are being medically evacuated to South
Africa ostensibly for non-contagious diseases may develop signs and symptoms suggestive of VHF or
other formidable infectious disease (eg avian influenza) in transit. It also occurs that patients suffering
from suspected VHF (or other notifiable disease) travel to South Africa on scheduled flights on their own
initiative, sometimes specifically to seek medical attention here, without declaring their illness to the airline.
Hence, aircrew members on commercial and medical evacuation flights should be trained to recognize the
following signs and symptoms suggestive of VHF (or other formidable infectious diseases) in passengers:

• Fever (≥38.5C) • Severe headache • Abnormal sweating

• Rapid breathing • Excessive coughing • Severe vomiting
• Diarrhoea • Bleeding - eg nosebleed or vomiting blood

The crew should attempt to isolate the patient and to avoid contact between the patient (or secretions and
excretions) and other passengers as best as can be managed under the circumstances. The pilot should
notify the control tower at the airport of intended arrival of the existence of the patient on board, and the
tower should arrange for the flight to be met by a PHO. The crew should complete form AC2 ‘for notification
of symptoms of a patient/sick passenger transported per aircraft to South Africa’, and this should be handed
to the PHO on arrival.

Screening procedures to detect febrile patients are increasingly being instituted within international airports
following the occurrence of the SARS and avian influenza pandemics of recent years, and this represents
a further method by which potential imported cases of VHF may be detected.

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Procedure on the arrival of a flight with a suspected or known VHF patient

The flight must be met by port health officials, including a medical officer if necessary, to assess the
patient and the likelihood that VHF is involved, and the doors kept closed (no disembarkation allowed) until
formalities have been completed. A duly completed form AC2 should be handed to the PHO if relevant.

Prior arrangements for patients arriving on medical evacuation flights to be transported by ambulance and
admitted to referral hospitals, should be permitted to proceed with due warning to the aircraft crew, ambulance
crew and the hospital concerned that VHF may be involved, so that appropriate safety procedures can be
instituted. If a suspected VHF patient arrives on a scheduled flight without prior arrangements for admission
to a hospital in South Africa, the PHO should arrange for transportation and admission of the patient to a
hospital designated for medical management of VHF patients (there should be standing arrangements
for PHOs to refer patients to designated hospitals through liaising with authorized contact persons at the
hospital – see 7.1.1: reaching a decision on transfer of VHF patients).

There should be a designated area within the airport for temporary isolation of patients awaiting transport
to a designated hospital. The pilot should permit the public address system to be used to inform the crew
and passengers calmly and factually that there is an ill person on board and to explain the precautionary
measures which are being taken, before disembarkation is allowed.
All passengers and crew members should be given an information sheet plus a Health Alert Notice which
is to be handed to a medical clinician should the person develop febrile illness within the ensuing 3 weeks.
Contact details for those crew members and passengers on the aircraft deemed to have been exposed to
possible infection should be recorded by the PHO and given to the office of the provincial Coordinator of
Communicable Disease Control (along with a complete passenger list) so that the persons at risk can be
placed under observation if deemed necessary (see section 7). In deciding which persons may have had
contact with the patient or secretions and excretions in such a manner as to have been exposed to possible
infection (see definitions in section 7) it is advisable to include passengers seated in same row (aisle to
aisle) as the patient, plus those seated in the two rows behind and the two rows in front of the patient.

People deemed to have been exposed to possible infection should be especially well briefed on the
precautionary measures and their responsibilities, if necessary in a room in the airport. The PHO should
assess the need for disinfection of affected parts of the aircraft cabin and arrange for this to be conducted
as described for ambulances (see under 7.1.3 above).

The use of transport isolators for conveyance of passengers by air

Transport isolators are not available except through the military services.

7.1.5 Importation of VHF patients into South Africa by land and sea

The importation of VHF patients into South Africa by land seems less likely than by air, but did occur in
1975 when two people who had been hitch-hiking in Zimbabwe developed Marburg disease shortly after

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 entering South Africa, with the subsequent occurrence of nosocomial infection in a health care worker in
Johannesburg.

There appears to be a real but small risk of importing cases of VHF into South Africa by sea, with the rat-borne
Seoul hantavirus being the most likely candidate. Moreover, there are well-documented instances where
crew members and passengers of ships sailing from tropical destinations were found to be suffering from
mosquito-borne infections such as yellow fever and dengue fever. It is believed that a ship sailing down the
east coast of Africa ignited a large epidemic of dengue fever in Durban in 1926 (before the causative agent
of the disease was known). Consequently, PHOs at sea ports of entry should maintain the same vigilance
and apply the same principles of VHF control as prescribed for major airports, including awareness of the
possible importation of disease through disembarkation of passengers and crew members at ports, as well
as through medical evacuation of sick persons from ships at sea by boat or helicopter.

7.2 Notification of cases of VHF

In terms of regulations promulgated under Health Act 61 of 2003, the VHFs are category A notifiable diseases
which should be reported to the Department of Health by telephone within 24 hours of being diagnosed,
with written notification on form GW17/5 (Figure 7.1) to follow within 5 days. However, it is important for
implementation of control measures that additional information should be supplied, including details of clinical
presentation, and this can be achieved conveniently by use of a checklist such as shown in Figure 7.2.

Notification should be made by the health care professional tending the patient as soon as possible after it
has been decided to proceed on the assumption that VHF may be involved, or after a diagnosis of VHF has
been confirmed, depending on which occurs first.

Reports should be made to the National Department of Health, Directorate: Communicable Disease Control
(CDC), Pretoria, plus the relevant Provincial Coordinator of CDC listed in Table 7.1 below. The National
Department of Health will notify World Health Organisation (WHO).

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Table 7.1: A list of contacts for notification and reporting of VHF outbreaks

Province Telephone Fax Cell phone Address

DoH, P/Bag X828,
National 012 395 8096 012 395 8906 082 419 9686
Pretoria 0001
DoH, P/Bag X5049,
Northern Cape 053 830 0529 053 830 0655 072 391 3345
Kimberley 8301
DoH, P/Bag X9051,
KwaZulu-Natal 033 846 7461 033 846 7759 083 457 1185
Pietermaritzburg 3200
DoH, P/Bag X11285,
Mpumalanga 013 766 3078 013 766 3473 082 229 8893
Nelspruit 1200
DoH, P/Bag X085,
Gauteng 011 355 3867 011 355 3338 082 335 3134
Marshalltown 2107
DoH, P/Bag X2068,
North West 018 397 2600 018 397 2693 082 770 3683
Mmabatho 0273
DoH, P/Bag X9302,
Limpopo 015 293 6062 015 293 6281 079 491 1909
Polokwane 0700
DoH, P.O Box 227,
Free State 051 408 1734 051 408 1074 083 452 8954
Bloemfontein 9300
DoH, P.O Box 2060,
Western Cape 021 483 3737 021 483 2682 083 488 0777
Cape Town 8000
DoH, P/Bag X0038,
Eastern Cape 040 608 0857 043 642 1409 083 378 0189
Bisho 5605
P.O Box 13113, Tramshed,
World Health Organisation 012 305 7725 012 305 7729
Pretoria, 0126

7.3 Public health response to VHF outbreaks

7.3.1 Immediate responsibilities of Provincial CDCs during outbreaks of VHF:

• Ensure that correct laboratory and autopsy investigations are undertaken to establish an aetiological
diagnosis (see section 4.3).
• Investigate the source of the outbreak.
• Trace and place under observation all VHF contacts in the community at large, beginning with the
family and cohorts of VHF patients (see below for definitions of contact and observation).
• Ascertain whether the hospital authorities are treating VHF patients under appropriate conditions of
isolation precautions, and whether the hospital infection control staff have traced and placed all health
care workers who have had contact with the patient/s or fomites under observation.
• Participate as necessary in the decision-making process as to whether VHF patients should be treated
in the primary hospital (the hospital where the diagnosis of VHF was first suspected) or should be
transferred to a referral hospital, and help facilitate approved transfers (see section 7.1).
• Supervise disposal of corpses of VHF patients (see section 6.5).
• Convene a VHF Outbreak Control Committee if necessitated by the circumstances of the outbreak as

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 indicated below.
• Collate information and disseminate it to those who need to be kept informed, including news media as
discussed below.
• Take any further action as may be appropriate and necessary to attain containment and control of the
VHF outbreak, and ensure that no fundamental steps or procedures are overlooked.

Indications for convening a VHF Outbreak Control Committee

Hospital staff and provincial CDC personnel can manage small outbreaks of indigenous VHF. For example,
where only one person develops Congo fever after being bitten by a tick it may only be necessary for provincial
CDC officials to warn family members and cohorts of the patient to take precautions against exposure to ticks
and blood of livestock, and to place persons potentially exposed to infection under observation for 2 weeks.
The virus is widely distributed in South Africa and it makes no sense to quarantine properties.

In contrast, the investigation and control of large outbreaks, or introduced exotic infections (diseases not
indigenous to South Africa), may require recruitment and coordination of large teams. Thus, the diagnosis
of Ebola fever in a nurse in Johannesburg in 1996 necessitated a search for the source patient, and the
identification and screening of about 1,500 potential contacts of the patients at two hospitals and in the
community at large, resulting in 350 persons being placed under 3 weeks observation and subjected to
intensive investigation if they became sick. It was necessary to co-opt administrators of the affected hospitals
plus a quarantine facility, infectious disease consultants, epidemiologists, military medical personnel, local
health authorities, plus members of ambulance, laboratory, mortuary and blood transfusion services, with
operations coordinated by a VHF Outbreak Control Committee which held daily meetings to monitor the
situation. Control of the 2008 outbreak of nosocomial infection with the novel Lujo virus in Johannesburg
required similar coordination.
A multi-disciplinary approach is crucial in public health when responding to large VHF outbreaks. This includes
doctors, nurses, epidemiologists, laboratory technicians, environmental health specialists, administrations
etc. The response should be organised by forming different sub-committees with roles and responsibilities as
shown in Table 7.2 below.

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 Table 7.2: Sub-committees responsible for the response to VHF outbreaks

SUB-COMMITTEE ROLE

Co-ordination and Coordinating all aspects of response, for example: selecting participating organisations,
logistics assigning responsibilities, managing information for public and media.

Confirmation of suspected cases and reporting the results to the relevant stakeholders
Laboratory
within 24 hours.
Case management,
infection control and Establish isolation facilities, implement isolation precautions, provide care to patients.
transportation of Training of health workers and cleaners. Safe transportation of patients.
patients
Developing case definition, active case finding and contact tracing, verification of
Epidemiology and rumour, investigation of suspected cases, collection of specimens from suspected
surveillance cases and deaths, data management, closely linked with case management,
environmental health, infection control, and social mobilization sub-committees.

Social mobilisation,
Liaise with different sub-committees to facilitate health promotion and media activities,
Health Promotion and
Liaise with local leadership and NGOs involved in activities on mobilizing communities.
Communication

Environmental Health Manages environmental factors related to the type of VHF.

Psychological support Support to patients, relatives and staff.

Writing all reports e.g. daily updates, preliminary and final report, and circulate to all
Report writing
stakeholders.

7.3.2 Tracing of contacts

The purpose of tracing VHF contacts and placing them under observation is to control spread of infection
and thus to terminate an outbreak. The office of the relevant provincial Coordinator of CDC is ultimately
responsible for tracing and observation of contacts. In practice, infection control officials within hospitals
where VHF patients are treated assume responsibility for placing health care workers who have had contact
with the patient/s or fomites under observation, and this is done irrespective of whether or not contact took
place before or after isolation precautions were instituted.

Concurrently, provincial CDC teams operate within the community at large to trace the movements of the VHF
patient/s for up to 3 weeks prior to onset of illness in order to establish the source of infection, and to prepare
a list of all contacts who are at risk of developing the disease and need to be placed under observation (a
period of 3 weeks prior to onset of illness applies for Marburg, Ebola, Lassa and Lujo fevers, but 2 weeks is
appropriate for Congo fever and other arbovirus diseases, see section 3).

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Definitions

An outbreak of VHF is the occurrence of one or more cases of VHF.

An index patient in an outbreak of VHF is the first patient in whom the disease is recognized, and is not
necessarily the primary case, i.e. is not necessarily the first person to have become infected in the outbreak.
Recognition of the disease in the index patient results in the discovery of the outbreak.

A multiple case outbreak of VHF can arise when there is secondary human-to-human spread of infection
from a primary case.

Common-source outbreaks occur when more than one primary case of infection arises from exposure to a
natural source of infection, e.g. infected animal tissues.

A source patient is a patient from whom transmission has occurred to produce secondary infection/s.

A contact is a person who has been exposed to an infected person, animal or contaminated environment in
such a manner as to have had the opportunity to acquire infection.

A case contact is a person who has been exposed to an infected person or his/her secretions, excretions,
blood or other tissues in such a way as to be at risk of acquiring infection.

A source contact is a person who has been exposed to the same external (non-human) source/s of infection
as an infected person.

Low risk contacts have had slight or indirect contact with a VHF patient or other source of infection on a
single or few occasions.

Moderate risk contacts have had close and prolonged contact with a VHF patient or other source of
infection. This category includes intimate friends of a VHF patient, relatives and health care workers.

High-risk contacts have had what is judged to be definite exposure to VHF infection, e.g. needle-stick with
blood from a confirmed case of VHF or similar exposure to animal tissues in a common-source outbreak.

Exposure to infection which constitutes contact for purposes of VHF control includes association with an
infected person at any time from onset of fever until 3 weeks later in any of the following ways:
• Sharing the same residence.
• Face-to-face contact (≤1 metre).
• Skin or mucous membrane contact or penetrating injury with the patient’s secretions, excretions,
blood or other tissues. This includes exposure to animal tissues or insect bites in situations where
such exposure is considered to be the source of infection.

In tracing and assessing persons potentially exposed to infection, interviews should be based on questionnaires
prepared specifically for the circumstances of the outbreak under investigation (see Figure 7.3 for an example).

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Persons assessed as having been exposed to infection as defined above, are included on a list of contacts
to be placed under observation.

7.3.3 Observation of contacts

Observation of contacts of VHF consists of recording temperatures twice daily for 3 weeks (21 days) from
the last date of contact with a VHF patient or fomite, and monitoring for signs and symptoms of illness. A 21
day observation period is appropriate for Marburg, Ebola, Lassa and Lujo fevers, but 14 days is adequate for
Congo fever, which has a shorter incubation period.

Rift Valley fever also has a short incubation period, but the virus seldom causes serious or haemorrhagic
disease and person-to-person spread has not been recorded, so active observation is not essential.

Persons with ongoing exposure to infection, such as health care workers engaged in nursing of VHF patients,
remain under observation while exposure continues to occur, and are kept under observation for the requisite
14 or 21 day period after the last date of potential exposure to infection.

Active observation involves contacts being seen twice daily by a medical official charged with this responsibility.
Passive observation entails the contact reporting (e.g. by telephone) on their own status to the observation
officer. Passive observation is sometimes applied to contacts deemed to be reliable, e.g. health care workers,
but this must not be permitted when VHF is involved.

It is important to note that the term observation is used in preference to surveillance since the terms
active surveillance and passive surveillance are used in a different sense to denote monitoring of a population
for the occurrence of a disease either actively through sampling a sub-population or passively through simply
testing samples submitted voluntarily to the laboratory.

Contacts should be seen at pre-arranged venues and times, which could include their place of employment,
e.g. a hospital, or their place of residence, e.g. a farm, and specific arrangements must be made for monitoring
of contacts at weekends or other times of absence from duty. All contacts must be seen twice daily at fixed
times and any unexplained absences from work or home must be investigated.

No medical official should be responsible for monitoring more contacts than can be conveniently managed;
in large outbreaks 10 contacts per monitor has been found to be convenient. Temperatures and illnesses
reported by contacts should be recorded on a standard list (see an example presented as Figure 7.3 and 7.4),
but care should be taken not to ask leading questions: let the contacts describe how they feel.

Low to moderate risk contacts of VHF (see definitions in 7.3.2 above), including health care workers, may be
kept under active observation in their normal environment and employment, but should not leave the town/
district until the observation period has ended. This provision is enforceable in law. High-risk contacts of VHF
(see definition in 7.3.2 above) must be kept under active observation or placed under quarantine in a suitable
facility for the duration of the quarantine period.

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It is not universally agreed that there is a need to confine high risk contacts to a quarantine facility, provided
they are kept under strict active observation. At most, confinement to a quarantine facility should be applied
selectively to those considered to be in imminent danger of developing infection, e.g. medical staff who have
had a needle-stick injury with blood known to be infected, or those who have developed non-specific illness,
e.g. fever and headache.

Quarantine facilities need not necessarily be in the same complex as VHF isolation units. Old infectious
disease hospitals in isolated localities are ideal, and since confinement of essentially healthy people may be
involved, it is advantageous to have access to an outdoor area.

Any contact who develops fever (temperature of 38°C or over) or signs and symptoms suggestive of VHF,
must be placed in isolation and treated as a suspected case.
Although monitoring of individual patients ceases on completion of the requisite 14 or 21 day period after the
last date of potential exposure to infection, outbreaks are only declared to be over after twice the duration
of this period has passed, 28 or 42 days since the last known potential exposure of any person to infection.
Hospital infection control and provincial CDC personnel must continue to monitor the situation during this
precautionary period.

Counselling of contacts and health care workers should be considered to counter stress during outbreaks.

7.4 Communication with the media

News media can be disruptive during outbreaks of VHF through disseminating incorrect and alarmist
information, and through making undue demands on the time of officials who are heavily engaged in
controlling the outbreak. However, with proper planning and liaison, the media can be utilized to dispel
misconceptions and to disseminate useful information. This is best achieved by conducting communications
with the media on an organized basis, and issuing factual, non-sensational statements through specially
appointed spokespersons who confine themselves to their areas of competence. For example:
• Spokespersons for the national and provincial Departments of Health can report on control measures,
VHF policy and the status of an outbreak.
• Members of NICD staff can provide background information on VHFs, including distribution and
occurrence of the diseases, sources of infection, means of spread and mortality. It is useful to have
succinct fact sheets on the diseases available for distribution.

Information must first be made known to those who have need of it, e.g. it is unacceptable for clinicians or
relatives of patients to hear of laboratory findings on the radio, or for officials of the Department of Health
to learn of the existence of an outbreak of VHF in the press. Although it is useful to issue approved press
statements at set times, it is advisable to have well-informed spokespersons readily available to the media.
Refusing to communicate or withholding information does not remove misconceptions. However, officials
should not volunteer sensitive information to outsiders or to the media.

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7.5 Long-term responsibilities of Provincial CDCs include:

• Drafting contingency plans for managing single or multiple case outbreaks of VHF in the province.
• Formulating policy as to whether cases of VHF should be referred to a specifically designated
hospital, or whether they should be managed in the hospital where the diagnosis is first suspected.
In practice, decisions will vary with individual circumstances.
• Acting in conjunction with the provincial Department of Health and Hospital Services to identify
and secure the use of facilities and resources needed for managing outbreaks and delegating
responsibilities, including the designation of specific hospitals as VHF referral centres (see section
immediately below).
• Assisting health care facilities to institute planning and training of health care workers in the
recognition, transport, isolation and nursing of patients.

7.6 Requirements for a VHF referral centre include:

• Tertiary care hospital which has been specifically designated for referral of VHF patients. It is usually
possible to adapt space within a hospital to serve as an isolation unit for nursing of VHF patients with
little or no structural alteration (see section 6.3).
• Laboratory unit capable of performing essential clinical pathology tests for monitoring the treatment
of VHF patients. It is best to use an existing laboratory, preferably but not necessarily within the same
complex as the patient isolation unit (see section 6.2).
• Quarantine facility for high-risk contacts of VHF patients, such as health care workers who develop
non-specific illness after known exposure to infection. Such persons are moved into the isolation unit if
a diagnosis of VHF is confirmed. A quarantine facility is seldom required, and it need not be in the same
complex as the isolation unit.
• Mortuary with facility for refrigerated storage of corpses until a diagnosis has been confirmed. This need
not be within the same complex as the isolation unit and does not require special facilities provided that
the corpse is properly disinfected and shrouded.
• Clinicians, nurses, infection control and laboratory personnel trained for evaluation, management,
nursing and laboratory monitoring of VHF patients with due isolation precautions.
• A senior person, logically a clinician (plus an alternate), authorized to take decisions on accepting
transfer of VHF patients, with appropriate consultation if necessary.
• An ambulance service with paramedical teams equipped and trained for safe transport of VHF patients.
• Personal protective and safety equipment required for transport and nursing of VHF patients.

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Figure 7.1: Form GW17/5 for notification of scheduled diseases

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 Figure 8: Suggested form for furnishing extra information on possible, probable or confirmed
Figurecases
7.2: of VHF.
Suggested form for furnishing extra information on possible, probable or confirmed cases of

National Department of Health Page 55 of 62

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 Figure 7.3: Suggested form for screening persons potentially exposed to VHF infection

Name................................................................ Age....... Sex....... Occupation.....................

Home address................................................... Work address...............................................................

.......................................................................... ......................................................................................
.......................................................................... ......................................................................................
Telephone.H...................................................... Telephone.W................................................................
Hospital............................................................. Hosp No..................Date of admission........................

Contact during last 3 weeks with: Yes No Remarks/dates

Suspected VHF patient... ... ... ... ... ... ... ... ... ................ ............. .........................................
Confirmed VHF patient.. ... ... ... ... ... ... ... ... ................ ............. ..........................................
Patient tissues/fomites (specify). ... ... ... ... ... ... ................ ............. ..........................................
Healthy animals (specify) ... ... ... ... ... ... ... ... ................ ............. ..........................................
Sick animals (specify) ... ... ... ... ... ... ... ... ... ................ ............. ..........................................
Animal tissues (specify ) ... ... ... ... ... ... ... ... ................ ............. ..........................................
Biting insects (specify)... ... ... ... ... ... ... ... ... ................ ............. ..........................................
Degree of contact: Yes No Remarks
Random/once only ... ... ... ... ... ... ... ... ... ................ ............. ..........................................
Several times... ... ... ... ... ... ... ... ... ... ... ................ ............. ..........................................
Shares residence ... ... ... ... ... ... ... ... ... ... ................ ............. ..........................................
Other (specify) ... ... ... ... ... ... ... ... ... ... ................ ............. ..........................................
Relationship to patient ... ... ... ... ... ... ... ... ……………………………...........................................
Interviewed by………………………………………….. Date……………... Place…………………………….

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 64
OBSERVATION OF VHF CONTACT FOR 21 DAYS FROM LAST DATE OF POTENTIAL EXPOSURE TO INFECTION
Name of contact person under observation......................................... Place of employment............................................................................ Tel W.....................................
Residential address.................................................................................................................................................. Tel H....................................... Cell ..................................
Date of last exposure to infection....................................................... Nature of exposure to infection..............................................................................................................
Name of observation officer (sign initials daily in row 3 below)......................................... Tel W................................................ Cell...........................................
Day of observation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Date
Seen by
am temperature
pm temperature
Headache
Neck rigidity
Mood changes
Muscle pain
Joint pain
Backache
Chest pain
Abdominal pain
Sore throat
Nausea
Vomiting
Diarrhoea
Jaundice
Rash
Bruising
Bleeding (specify)
Figure 7.4: Suggested checklist for observation of individual VHF contact person

Other (specify)

National Department of Health

 8. Key References

Swanepoel, R. (1985) Recognition and management of viral haemorrhagic

fevers: a handbook and resource directory. Sandringham: National Institute for
Virology, Department of Health, South Africa.

Swanepoel, R. (1987) Recognition and management of viral haemorrhagic

fevers: a handbook and resource directory, 2nd edition. Sandringham: National
Institute for Virology, Department of Health, South Africa.

CDC.(1988) Management of patients with suspected viral hemorrhagic fever.

MMWR; 37 (no. S-3);1-15.

CDC. (1995) Notice to Readers Update: Management of Patients with

Suspected Viral Hemorrhagic Fever - United States. MMWR; 44(25);475-479.

CDC and WHO. (1998) Infection Control for Viral Haemorrhagic Fevers in the
African Health Care Setting. Atlanta: CDC.

Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection

Control Practices Advisory Committee, CDC. (2007) Guideline for Isolation
Precautions: Preventing Transmission of Infectious Agents in Healthcare
Settings

National Guidelines on Epidemic Preparedness and Response. (2009)

Department of Health, South Africa.

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 9. APPENDIX 1: FREQUENTLY ASKED QUESTIONS ON
CRIMEAN-CONGO HAEMORRHAGIC FEVER
Q: What is a viral haemorrhagic fever?
A: A viral haemorrhagic fever is a disease which is caused by a virus and has a tendency to disturb blood
clotting, so that patients may develop uncontrolled bleeding or “haemorrhaging”. Many common diseases
can resemble viral haemorrhagic fever, but the term is reserved for a particular group of diseases associated
with a high death rate. In Africa, these include Crimean-Congo haemorrhagic fever, Lassa fever, Marburg
disease and Ebola fever. Apart from the fact that they cause similar disease, the viruses are not closely
related to each other, and are transmitted in a variety of ways.

Q: What is Crimean-Congo haemorrhagic fever?

A: Crimean-Congo haemorrhagic fever is a tick-borne viral disease of humans which occurs in Africa, Eastern
Europe and Asia.

Q: Why does it have the name “Crimean-Congo haemorrhagic fever”?

A: A disease given the name Crimean haemorrhagic fever was first recognized on the Crimean Peninsula in
1944, although the virus which causes the disease was only identified in 1967. Meanwhile, in 1956 a virus
given the name Congo was isolated from a child with fever in the former Belgian Congo (now Democratic
Republic of the Congo). In 1969 it was discovered that the two viruses were the same. Consequently, the
virus and the disease are called “Crimean-Congo haemorrhagic fever”. The name is often abbreviated to
“CCHF”, and in South Africa the disease is commonly called “Congo fever”.

Q: Where does the virus come from?

A: The virus is transmitted mainly by Hyalomma ticks, which have distinctive brown and white bands on their
legs, and are known in South Africa as bont-legged ticks (Afr.: bontpootbosluise). The virus can remain in the
ticks for long periods, and even pass through the eggs to infect the next generation of ticks.

There are three species of Hyalomma in South Africa, and although they are widely distributed the ticks tend to
be most numerous in the drier north-western parts of the country - the Karoo, western Free State, Northern
Cape and North-West Province.

Immature Hyalomma ticks (larvae and nymphs) feed on ground birds such as guinea fowl, and small mammals
up to the size of hares. Adult Hyalommas feed on livestock such as cattle, sheep and goats, as well as wild
animals such as antelope, and also ostriches.

Animals bitten by infected ticks do not develop the disease, but can circulate the virus in their blood for a few
days, up to a week, and thereafter become immune to further infection. Non-infected ticks become infected
if they feed on the animals during the short period when virus is in circulation, thus ensuring that the virus is
perpetuated.

Q: How do humans become infected?

A: Humans can become infected from being bitten by infected ticks, or even from squashing ticks if fluid from
the ticks gets into cuts and breaks in the skin, or onto mucous membranes. Fortunately immature Hyalommas
feed only on small animals and do not bite humans, and adult Hyalommas prefer farm animals and so seldom

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bite humans. If humans were preferred hosts of Hyalomma ticks, there would be many more cases of the
disease.

Humans can also become infected if blood from infected livestock or wild animals comes into contact with
broken skin (cuts and abrasions) or mucous membranes during the short period that the animals have the
virus in circulation. On farms, this usually happens when young animals become infected as a result of being
exposed to ticks, and humans are then exposed to blood during procedures such as the castration of calves,
slaughtering of lambs, vaccination of animals, the cutting of identity notches in the ears, or the attachment of
ear tags. Occasionally animals that have been reared under tick free conditions come into contact with ticks
and the virus late in life, and so slaughtering mature animals can also result in human infection. Although
the proportion of mature animals that will have virus in circulation may be extremely low, many thousands of
animals are slaughtered each day at abattoirs. Hunting and butchering of wild animals can also be a source
of human infection.

Similarly, humans can become infected if blood or blood-tinged body fluids and wastes from patients with the
disease comes into contact with broken skin or mucous membranes, as occurs when medical care personnel
sustain accidental needle sticks.

Q: Which people are at risk of becoming infected?

A: People who are at particular risk include those involved in the livestock industry, such as farmers and farm
labourers, veterinarians, abattoir workers, persons who slaughter animals informally, and hunters.

Within abattoirs those who come into contact with fresh blood are at greatest risk. Once carcases have been
bled out and hung to mature there is a sudden increase in acidity of the meat and virus cannot be detected
in the carcase. Ostriches appear to be the only birds in which there is similar circulation of detectable levels
of virus in blood as occurs in mammals. There is no indication that meat processed and matured according
to standard abattoir practice constitutes a danger to consumers. Half-fed ticks which detach from the hides
of recently slaughtered animals may attach indiscriminately to hosts available in their environment, and thus
infect slaughtermen.

Apart from people directly involved in the livestock industry, persons at risk of being bitten by ticks include
those who live in the countryside and town dwellers who visit the countryside for occupational or recreational
purposes, including hunting and hiking. People are not always aware of being bitten by ticks. In patients with
Congo fever, ticks have been found attached in concealed sites such as on the scalp and between the toes.

Occasionally, no direct evidence can be obtained to indicate that a patient with Congo fever had contact with
animal blood or with ticks, and the only evidence to suggest possible exposure to infection is the fact that the
patient lived in or visited an environment where such contact was possible.

Health care personnel or close associates of a patient can acquire infection from contact of broken skin
or mucous membranes with blood or blood-tinged body fluids and wastes of the patient. Although spread
of infection to family members has never been recorded in South Africa, it is possible. The only time that

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infection has been seen in groups of people is when they have been exposed together to a common source
of infection, as in slaughtering animals. In contrast, there have been several instances of secondary spread
of infection from patients to health care personnel, and this has usually involved needle stick injuries in
hospitals.

Q: How common is the disease and how often is it fatal?

A: In brief, about 1-10 cases of Congo fever are diagnosed each year in South Africa (range 0-20), and 20-
25 percent of patients die, but the death rate can be 30-50 per cent if patients do not receive proper medical
attention.

More exactly, 158 cases of Congo fever have been diagnosed in Southern Africa from the time that the
presence of the disease was first recognized in 1981 up until the end of 2000, with one infection having
occurred in Zaire, one in Tanzania, ten in Namibia and the remainder in South Africa. Most patients were
employed in the livestock industry, and males constituted 129/158 of cases.

Marginally the largest group of cases, 67/158 (42,4%), arose from known tick bite or squashing of ticks; a
similar number, 66/158 (41,8%), arose from known or potential contact with fresh blood or other tissues of
livestock and/or ticks; 7/158 (4,4%) nosocomial infections arose from contact with blood or items contaminated
with blood of known Congo fever patients, while in 18/158 (11,4%) cases there was no direct evidence of
contact with livestock or ticks, but the patients lived in or visited a rural environment where such contact was
possible.

Q: What are the signs and symptoms of the disease?

A: The disease has a short incubation period followed by a very sudden onset of illness. People usually
become sick within 1-3 days of being bitten by a tick, or 5-6 days (occasionally longer) after exposure to the
blood of infected livestock or humans. (The short incubation period and sudden onset are among several
points of distinction with tick bite fever.)

Patients abruptly develop a severe headache with sore and reddened eyes, fever with cold chills, and intense
body pains, particularly involving the muscles of the lower back and thighs. The patients feel extremely unwell
and usually take to their beds. Body temperatures do not necessarily remain high and may fluctuate in the
course of each day. There may be nausea and vomiting, and sometimes abdominal pain and diarrhoea
early in the disease. At this stage, blood tests already show disturbed liver function, and a decrease in blood
platelets, which are involved in the clotting of blood.

After about 5 days patients may develop a rash of pink blotches on the body, followed by various bleeding
tendencies, depending on the severity of the illness. They bruise easily, often have nose bleeds, and may
pass blood in the stool and urine. Stools seldom contain fresh blood; they usually have a dark and tarry
appearance. Small or large red spots of bleeding into the skin appear, and there may be large confluent areas
of bleeding into the skin around injection sites and in skin folds such as in the armpits or groin. Patients may
vomit blood and bleed from the gums, and women may develop heavy uterine bleeding. Blood continues
to ooze from needle puncture sites. There can also be internal bleeding, including intracerebral bleeding.

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Patients go into a coma as liver, kidney and lung functions fail, and death occurs 5-14 days after onset of
illness, usually from heart failure.

Patients who recover show sudden improvement from day 10 of illness onwards. Virus remains detectable
in human blood for up to two weeks after the onset of illness, but once the results of blood tests indicate
that patients’ body functions have recovered, and they feel well and are no longer bleeding, they can be
discharged from hospital. Although there has been no indication that virus continues to be excreted in body
fluids, patients should refrain from intimate contact with other people for six weeks after recovery from the
disease as a precaution against spread of infection. Convalescent patients should not undertake heavy duties
during this period. After recovery patients are immune to further infection. It is not uncommon for recovered
patients to remember little or nothing about the events of their illness.

Treatment essentially consists of supportive therapy, which comprises intravenous feeding of the patient and
replacement of blood and clotting factors. Severely ill patients may be placed on ventilators and other life
support systems. The chemotherapeutic drug ribavirin has been used to treat patients on a trial basis, but the
intravenous form of the drug which is required for seriously ill patients, is virtually unobtainable since it is only
produced intermittently on account of low demand.

Q: What action should be taken if a person is suspected of having the disease?

A: The disease may be suspected when a person suddenly becomes sick with headache, fever and chills,
muscle pains, and possibly nausea, vomiting and diarrhoea, less than a week after being bitten by a tick,
squashing ticks, or coming directly into contact with fresh blood or blood-tinged body fluids and organs of
livestock, wild animals or human Congo fever patients.

A doctor should be consulted immediately the disease is suspected, and if the doctor believes that the
suspicion is justified then arrangements should be made to send blood samples (blood taken with the anti-
coagulant EDTA, plus clotted blood) expeditiously to the Special Pathogens Unit of the NICD in Johannesburg
for confirmation of the diagnosis. It should be remembered that the vast majority of suspected cases prove
not to be Congo fever, and if there is doubt the doctor should consult physicians specifically charged with
handling viral haemorrhagic fever patients in the province concerned, or members of staff of the Special
Pathogens Unit.

Certain major hospitals have been designated for the management of haemorrhagic fever patients in each
province. Medical personnel should establish for themselves what arrangements exist in their own province.
Immediately after a Congo fever or any other haemorrhagic fever is suspected, medical personnel should
ensure that they apply strict precautions against infection from blood and other body fluids. On no account
should patients suspected to be suffering from any haemorrhagic fever be referred to a hospital without first
discussing the case with the relevant clinicians. Specimens should not be sent to the Special Pathogens Unit
without first contacting the Unit.

The doctor (or other health worker certified as competent to diagnose) who makes the diagnosis has a legal
obligation to notify the Local Authority Health Services of the existence of the case on form GW17/5.

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Q: What precautions should be applied to persons who have potentially been exposed to infection?
A: Local and provincial health officials are responsible for investigating the circumstances surrounding
confirmed cases of the disease, and instituting such control measures as may be necessary. Persons in
the community at large, including family members, who have been in contact with confirmed Congo fever
patients, or who have been exposed to the same potential source of infection, are classified as being at
zero, low, moderate or high risk according to defined criteria, and placed under appropriate observation
as discussed below. Medical personnel who have been exposed to patients are separately placed under
observation of the infection control officials of the institution concerned.

Contacts considered to be at high risk would, for instance, include persons who have had accidental injury
with a needle contaminated with the blood of a confirmed Congo fever patient. Such persons would be
placed under active observation, which consists of reporting twice a day to a designated health official to
be monitored for signs and symptoms of the disease and to have their temperature recorded for a period of
two weeks after last contact with the patient (calculated to exceed the incubation period of Congo fever by a
wide margin of safety - the observation period would be extended to three weeks for most of the other viral
haemorrhagic fevers). Low risk contacts of confirmed patients, who have not had closer than one metre face-
to-face contact with the patient for instance, may be placed under passive observation, which could consist
of reporting to the responsible health official daily by telephone rather than in person.

Note that persons under observation are not in quarantine and may continue with their normal duties, including
attending to patients. They are only considered to be infectious once they become sick themselves. As soon
as they develop signs and symptoms considered to be characteristic of the disease, or a fever of 38,5℃ or
greater, they are admitted to hospital as suspected cases.

Places such as abattoirs constitute a special case. Since exposure potentially occurs on a continuing basis
(although the risk is actually low), there is seldom an indication for placing selected individuals under special
observation. Instead, clinics attached to abattoirs should maintain a high degree of awareness of Congo fever
and other diseases which can be acquired from livestock, and ensure that there is appropriate investigation
of sick members of staff.

Family members and co-workers of patients who become infected on farms may be placed under observation
depending on their degree of potential exposure to infection, but since the ticks and virus are so widely
distributed there is no logic in placing farms under quarantine.

Q: What measures can be taken to prevent exposure to infection?

A: Persons potentially exposed to tick bite can use certain pyrethroid acaricides to treat clothing such as socks
and trousers (acaricides are insecticides used against ticks). Formulations which are generally available
from shops that sell equipment for camping and outdoor activities, include aerosol sprays and sachets of
concentrated acaricide used to prepare emulsions into which clothing is dipped.

Abattoir workers, veterinary staff, farm workers and hunters should use appropriate impervious protective
clothing and gloves when engaged in activities which carry a risk of exposure to animal blood. Although it

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is incumbent upon employers to supply protective clothing and instruction in safety, employees must take
responsibility for adhering to safety regulations.

Veterinary regulations promulgated for ostrich abattoirs require that birds should be treated with an appropriate
acaricide and held in tick-free circumstances for 14 days before slaughter. Similar regulations would be
impossible to implement for other livestock. Vast numbers of cattle, sheep and goats are slaughtered each
day, and the costs of constructing tick-free holding pens of suitable capacity would be prohibitive, as would the
costs and logistics of holding and feeding the animals and supervising the operation. A potential alternative
would be the development of a veterinary vaccine that is applied to farm animals as a public health measure,
but such research would require special funding.

At present there is no human vaccine, and the lack of potential demand for such a vaccine inhibits its
development.

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