1998 Guidelines on the Management and Control of Viral Haemorrhagic Fevers issued by the Departments of Health in Britian

The following are abstracts from new guidelines on risk categories and initial management. Copies are available from the Department of Health, PO Box 410, Wetherby, LS23 7LN and also on Internet site

Risk Categories

Minimum risk
This category includes febrile patients who:

• have not been in known endemic areas before the onset of illness; OR have been in endemic areas (or in contact with a known or suspected source of a VHF) but in whom the onset of illness was definitely more than 21 days after their last contact with any potential source of infection.

Moderate risk
This category includes febrile patients who:

• have been in an endemic areas during 21 days before the onset of illness, but who have none of the additional risk factors which would place him or her in the high risk category; OR not been in known endemic area but who may have been in adjacent areas or countries during the 21 days before the onset of illness, and who have evidence of severe illness with organ failure and/or haemorrhage which could be due to a VHF and for which no alternative diagnosis is currently evident.

High risk
This category includes febrile patients who:

• have been in an endemic area during the three weeks before illness AND
• have lived in a house or stayed in a house for more than 4 hours where there were ill, feverish persons known or strongly suspected to have a VHF, OR took part in nursing or caring for ill, feverish patients known or strongly suspected to have a VHF, or had contact with the body fluids, tissue or the dead body of such a patient; OR are a laboratory health or other worker who has, or has been likely to have come into contact with body fluids, tissue or the body of a human or animal known or strongly suspected to have a VHF; OR were previously categorised as a ‘moderate’ risk but who have developed organ failure and/or haemorrhage.
• have not been in an endemic area but during the three weeks before illness they; cared for a patient or animal known or strongly suspected to have a VHF or came into contact with the body fluids, tissues or dead body of such a patient or animal; OR handled clinical specimens, tissues or laboratory cultures known or strongly suspected to contain the agent of a VHF.

Initial Management of Patients

Minimum risk
Minimum risk patients may, if necessary, be admitted to a general hospital, or to an infectious diseases department. If there is no immediate threat to life (malaria being excluded) patients may remain at home. Patients in hospital should be managed with standard isolation techniques (ie good clinical practice, universal precautions, and safe disposal procedures). Over 95% of seriously ill patients in the minimum risk category will have malaria and symptoms will resolve with appropriate antimalarial treatment. The Infection Control Team should be informed before the patient is admitted after admission. The Consultant in Pubic Health Medicine (CPHM) may also wish to be informed in certain circumstances, and the locally agreed procedures should be included in routine infection control policies. For patients in the minimum risk category, it is not anticipated that any public health action will be needed; statutory notification of suspected VHF is not recommended at this level. Patients may be transported by ambulance without special precautions.

Moderate Risk
Moderate risk patients should be admitted either to the Department of Health designated High Security Infectious Disease Units (HSIDUs) at Coppett’s Wood Hospital, north London or Newcastle General Hospital or to immediate isolation facilities after consultation with the physician in charge. The CPHM should be notified of a suspected case in the moderate category. The aim is to provide a high level of infection control for patient care and particularly for laboratory procedures while an alternative non-VHF diagnosis is sought. In more than 95% of cases malaria will be the alternative diagnosis. Virological tests for VHF are therefore generally not indicated for moderate risk patients. The initial malaria test may be carried out locally, but other patient management specimens should be sent in accordance with the defined procedures (described elsewhere in the guidelines) to a HSID laboratory. Contacts should be identified by the CPHM but unless the patient is recategorised as high risk the contacts need not be placed under surveillance. The ambulance service will usually transport the patient as an Ambulance Category III removal. Any special needs will be advised by the clinician in charge of the designated HSIDU.

High risk
Any patient known or strongly suspected to be suffering from a VHF should be admitted to one of the HSIDUs. Ambulance transport of the patient should be as an Ambulance Category III removal, with any special needs being advised by the clinician in charge of the designated HSIDU. The CPHM should identify close contacts, place them under surveillance and liaise with other CPHM’s on the identification of contacts who may be in other districts. The national surveillance and control units for England, Wales, Northern Ireland and/or Scotland should be involved. Blood and body fluids from such patients are likely to contain high concentrations of virus. Specimens for patient management tests from high risk or confirmed patients must be sent to a HSID laboratory. Specimens from virological investigations must be sent to an HSID viral diagnostic laboratory equipped to handle Hazard Group 4 biological agents.