C:windowsTEMPCID199~2.CDR

Infection Control for
Viral Haemorrhagic Fevers


in the African
Health Care
Setting


World Health Organization


U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES CDC
Public Health Service


CENTERS FOR DISEASE CONTROL


AND PREVENTION




C. J. Peters, M.D., Chief


Special Pathogens Branch


Division of Viral and Rickettsial Diseases


National Center for Infectious Diseases


Centers for Disease Control and Prevention


Guenael Rodier, M.D., Chief


Epidemiological Surveillance and Epidemic Response


Division of Emerging and Other Communicable Diseases


World Health Organization


Developed and written by:


Ethleen Lloyd, M.S., C.H.E.S., Health Communication Specialist
Special Pathogens Branch (CDC)


Helen Perry, M.A., Educational Design Specialist
Special Pathogens Branch (CDC)


Layout and design by:


Lilien Yang, M.S., Visiting Fellow
Special Pathogens Branch (CDC)


Illustrations by:


Willie Richardson, A.A., Visual Information Specialist
Division of Media and Training Services, Public Health Program Practice Office (CDC)


The material in this manual is in the public domain. It may be used and reprinted without permission. The


source should be acknowledged. Suggested citation: Centers for Disease Control and Prevention and World


Health Organization. Infection Control for Viral Haemorrhagic Fevers in the African Health Care Setting.


Atlanta, Centers for Disease Control and Prevention, 1998: 1-198.




Infection Control


for Viral Haemorrhagic Fevers


in the African Health Care Setting


December 1998


This manual was prepared by:


Centers for Disease Control and Prevention: National Center for Infectious Diseases,
Division of Viral and Rickettsial Diseases, Special Pathogens Branch, WHO Collaborating
Centre for Viral Haemorrhagic Fevers


and


World Health Organization: Division of Emerging and Other Communicable Diseases -­
Surveillance and Control




Acknowledgements


The contributions of the following organizations to the preparation and review of this
document are gratefully acknowledged:


Centers for Disease Control and Prevention


Hospital Infections Program
Office of Health and Safety


World Health Organization


WHO Regional Office for Africa
WHO Country Programmes in Kenya and Gabon


Centre International de Recherches Médicales de Franceville, Gabon


Communicable Disease Surveillance Centre, United Kingdom


Dr. Kalongi and the staff of Clinique Bondeko, République Démocratique du Congo


École de Médecine, Université de Kinshasa, République Démocratique du Congo


Épicentre, France


Fogarty International, USA


Hôpital Général de Kikwit, République Démocratique du Congo


Institut de Médecine Tropicale, Belgium


Institut de Recherche Biologique Appliquée de Guinée


Institut Pasteur à Paris, France


Institute of Virology, Germany


Johns Hopkins School of Public Health, USA


Lassa Fever Research Projects, Guinea, Sierra Leone


Medical Emergency Relief International, United Kingdom


Médecins Sans Frontières, Belgium


National Institute of Virology, South Africa


Participants attending the CDC WHO VHF Isolation Precautions workshops held
at Mumias, Kenya, and Booué, Gabon


Swedish Institute for Infectious Diseases, Sweden


Tulane University, USA


United States Army Medical Research Institute of Infectious Diseases, USA


Virus Research Centre, Kenya Medical Research Institute, Kenya


Yale University, USA




Table of Contents


Introduction 1


Viral Haemorrhagic Fevers: An Overview 3


How VHF Is Transmitted in the Health Care Setting 4


What Is in This Manual 5


Who the Manual Is For 5


Objectives 5


How to Use the Manual 6


Glossary for Use with This Manual 8


Section 1 Use Standard Precautions with All Patients 9


1.1 Use Standard Precautions 11


1.2 Establish and Maintain a Minimum Level of Standard
Precautions 12


1.3 Establish Routine Handwashing 12


1.4 Handle and Dispose of Sharp Instruments Safely 14


1.5 Disinfect Reusable Needles and Syringes Safely 15


1.6 Disinfect Disposable Needles and Syringes That Must Be
Reused 15


1.7 Use VHF Isolation Precautions 16


1.8 Select a VHF Coordinator 18


Section 2 Identify Suspected Cases of VHF 19


2.1 Use Information from Previous Outbreaks to Suspect a VHF 22


2.2 Begin VHF Isolation Precautions 25


2.3 Alert Health Facility Staff about Specific Risk for VHF
Transmission 25




2.4 Report the Suspected Case to the Health Authorities 27


2.5 Identify Patient’s Contacts and Travel History 28


Section 3 Isolate the Patient 29


3.1 Select Site for the Isolation Area 31


3.2 Plan How to Arrange the Isolation Area 32


3.3 Gather Recommended Supplies 34


3.3.1 Plan Disinfection for VHF-Contaminated Items 34


3.3.2 Gather Supplies for the Patient Area 35


3.3.3 Gather Supplies for the Changing Room 36


3.3.4 Arrange for Storing of Supplies Outside the Changing
Room 36


3.4 Set Up Changing Rooms 37


3.5 Place Security Barrier Around Isolation Area 37


3.6 Consult Family Members about Patient Care 39


Check List: Supplies for a Changing Room 41


Check List: Supplies for Patient Area 42


Section 4 Wear Protective Clothing 43


4.1 Specify Who Should Wear Protective Clothing 45


4.2 Gather a Supply of Protective Clothing 46


4.3 Put On Protective Clothing 53


4.4 Take Off Protective Clothing 57


Section 5 Disinfect Reusable Supplies and Equipment 65


5.1 Prepare Bleach Solutions 68


5.2 Prepare Supply of Soapy Water 72


5.3 Disinfect Gloved Hands between Patients 73


5.4 Disinfect Used Gloves before Reuse 74




5.5 Disinfect Reusable Medical Instruments 75


5.6 Disinfect Bedpan or Waste Bucket 76


5.7 Disinfect Patient’s Utensils 76


5.8 Disinfect Spills of Infectious Body Fluids 77


5.9 Disinfect Infectious Waste and Non-Reusable Supplies for
Burning 78


5.10 Clean and Disinfect Protective Clothing 79


5.11 Clean and Disinfect Boots 79


5.12 Clean and Disinfect Patient’s Bedding 80


5.13 Give First Aid for Accidental Exposures 81


Section 6 Dispose of Waste Safely 83


6.1 What Needs Disposal 85


6.2 Select Staff to Supervise Waste Disposal and Burning 87


6.3 Train and Supervise Staff to Carry Out Waste Disposal 87


6.4 Select Site for Burning VHF-Contaminated Waste 89


6.5 Use Incinerator to Burn VHF-Contaminated Waste 89


6.6 Use Pit to Burn VHF-Contaminated Waste 92


6.7 Take Steps to Ensure Security of Burning Site 93


Section 7 Use Safe Burial Practices 95


7.1 Prepare the Body Safely 97


7.2 Transport the Body Safely 98


7.3 Prepare Burial Site 98


7.4 Disinfect the Vehicle after Transporting the Body 99




Section 8 Mobilize Community Resources and Conduct Community
Education 101


8.1 Identify Key Community Resources 104


8.2 Meet with Community Leaders and Assess the Current Situation 106


8.3 Describe the Target Population 108


8.4 Describe Problems Contributing to Transmission Risk 108


8.5 Identify Changes or Actions Required 108


8.6 Identify Barriers to Carrying Out Recommended Changes or
Actions 109


8.7 Develop Specific Messages 109


8.8 Select Activities for Communicating Messages 110


8.9 Assign Tasks and Carry Out Activities 110


8.10 Evaluate Activities 111


8.11 Obtain Community Feedback 112


8.12 Meet Regularly with the Mobilization Committee 112


Section 9 Make Advance Preparations to Use VHF Isolation Precautions 113


9.1 Identify a VHF Coordinator to Oversee Preparations 115


9.2 Assess Current Readiness for VHF Isolation Precautions 116


9.2.1 Monitor Routine Handwashing Practices 116


9.2.2 Assess Readiness for Identifying Suspected VHF Cases 117


9.2.3 Assess Readiness for Setting Up a VHF Isolation Area 117


9.2.4 Assess Readiness for Medical, Laboratory, and Cleaning
Staff 117


9.3 Train Health Facility Staff in VHF Isolation Precautions 118


9.4 Plan for Community Mobilization 121


9.5 Assess Current Supplies and Equipment 122


9.6 Periodically Reassess Supplies 122


VHF Isolation Precautions Supplies 123




Annex 1 Standard Precautions for Hospital Infection Control 133


Annex 2 Specific Features of VHFs 135


Annex 3 Planning and Setting Up the Isolation Area 141


Annex 4 Adapting VHF Isolation Precautions for a Large Number of
Patients 145


Annex 5 Making Protective Clothing 149


Annex 6 Requirements for Purchasing Protective Clothing 153


Annex 7 Disinfecting Water for Drinking, Cooking and Cleaning 157


Annex 8 Preparing Disinfectant Solutions by Using Other Chlorine
Products 161


Annex 9 Making Supplies: Sharps Container, Incinerator, and Boot
Remover 163


Annex 10 Sample Job-Aids and Posters for Use in the Health Facility 165


Annex 11 Laboratory Testing for VHFs 171


Annex 12 Skin Biopsy on Fatal Cases for Diagnosis of Ebola 173


Annex 13 Community Education Materials 181


Annex 14 Conducting In-Service Training for VHF Isolation Precautions 185


Annex 15 Local Resources for Community Mobilization and Education 187


Annex 16 International and Regional Contacts 189


References 193


Index 197




Figure List


Figure 1 Epidemiological graph of the Ebola hemorrhagic fever outbreak in
Kikwit, 1995 3


Figure 2 An example of a handwashing station 13


Figure 3 Parts of hands that are often missed during handwashing 13


Figure 4 Standard sharps container 14


Figure 5 Using plastic bottle to dispose of used needles 14


Figure 6 Placing the disposable needle and syringe in soapy water 15


Figure 7 An example of VHF Isolation Precautions poster 26


Figure 8 A sample layout of an isolation area 32


Figure 9 A sample layout for a single patient 33


Figure 10 A sample layout for several patients 33


Figure 11 A security barrier and sign 37


Figure 12 An example of a sign-in sheet 38


Figure 13 Inner layer of clothing 46


Figure 14 Thin gloves 46


Figure 15 Using plastic bags as boots 47


Figure 16 Storing boots 47


Figure 17 Gown with ties 48


Figure 18 Wearing a plastic apron 48


Figure 19 Thick gloves 49


Figure 20 Using plastic bags as gloves 49


Figure 21 HEPA-filter mask 50


Figure 22 Surgical mask 51




Figure 23 Cotton mask 51


Figure 24 Head covering 51


Figure 25 Wearing clear eyeglasses or goggles 52


Figure 26 Scrub suit 53


Figure 27 Putting on boots 53


Figure 28 Putting on the first pair of gloves 54


Figure 29 Putting on the outer gown 54


Figure 30 Putting on a plastic apron 55


Figure 31 Proper way to put on the second pair of gloves 55


Figure 32 Putting on mask 55


Figure 33 Putting on head cover 56


Figure 34 Putting on eyewear 56


Figure 35 Disinfecting the boots 57


Figure 36 Disinfecting / disposing of used gloves 58


Figure 37 Removing the apron 59


Figure 38 Removing the gown 59


Figure 39 Washing the gloved hands 59


Figure 40 Removing the eyewear 60


Figure 41 Removing the head cover 60


Figure 42 Removing the mask 60


Figure 43 A boot remover 61


Figure 44 Removing the inner gloves 61


Figure 45 Marking container for mixing 1:10 bleach solution 69


Figure 46 Preparing bleach solutions 70




Figure 47 Preparing bleach solutions during an outbreak 71


Figure 48 Small piece of cake soap 72


Figure 49 Checking gloves for holes 74


Figure 50 Disinfecting a spill on the floor 77


Figure 51 Disinfecting a spill on the wall 78


Figure 52 Transferring laundry to the cleaning area 79


Figure 53 Cleaning patient’s bedding 80


Figure 54 A 220-litre drum 89


Figure 55 Making an incinerator 90


Figure 56 Making an incinerator 90


Figure 57 A completed incinerator 91


Figure 58 Disinfecting the vehicle after transporting the body 99


Figure 59 Meeting community leaders 107




Introduction


African countries (shaded areas) where viral haemorrhagic fevers have been


documented in the past




2




Non health care workers


Health care workers


Viral Haemorrhagic Fevers: An Overview


In Africa, viral haemorrhagic fevers (VHFs) include Lassa fever, Rift
Valley fever, Marburg and Ebola haemorrhagic fevers,
Crimean-Congo haemorrhagic fever (CCHF) and yellow fever.
Humans initially contract an infection with a haemorrhagic fever
virus through exposure to rodents or insects (for Ebola and
Marburg VHFs, the natural reservoir is unknown).
Person-to-person transmission of Lassa, Ebola, Marburg and CCHF
viruses can occur through direct contact with VHF-infected
material.


Typically, during the course of a VHF, the blood vessels and many
organ systems are damaged. VHFs are often accompanied by
bleeding, reflecting the widespread presence of the virus
throughout the patient’s body. As a result, the blood, urine,
vomitus, pus, stool, semen and saliva from the VHF patient are
infectious. This is why VHFs pose a serious risk to caregivers in
the health care setting and in the community.


The transmission risk of VHFs in the health care and laboratory
setting is well documented. During the 1995 Ebola haemorrhagic
fever outbreak in Kikwit (former Zaire, and now the Democratic
Republic of the Congo), one fourth of the cases were in health care
workers with a history of recent patient care.1 After barrier nursing
practices (such as wearing protective clothing) were implemented,
the risk of transmission was reduced. No new cases were reported
among health care workers who used these practices. (Fig.1)


Health staff began


using VHF Isolation Number of deaths
12 Precautions


10


Health care workers


Non health car workers


8


6


4


2


0


31- 4- 8- 12- 16- 20- 24- 28- 2- 6- 10- 14- 18- 22- 26- 30- 3- 7- 11- 15- 19­


Mar Apr Apr Apr Apr Apr Apr Apr May May May May May May May May Jun Jun Jun Jun Jun


Date of ons e t of s ymptoms


Fig. 1. The number of infected health care workers declined after barrier nursing practices
were begun during the Ebola haemorrhagic fever outbreak at Kikwit, 1995. One case
resulted from an inappropriate use of barrier nursing practices.


Khan AS et al. The Reemergence of Ebola Hemorrhagic Fever, Journal of Infectious Diseases, in press,
1998.


3


1




How VHF Is Transmitted in the Health Care Setting


The virus enters the health facility in the body
fluids of a VHF patient


All health care staff, laboratory staff, cleaning
staff, other patients and visitors to the health


facility are at risk for exposure to VHF.


The virus is transmitted during direct,
unprotected contact with a VHF patient OR with


a deceased VHF patient.


The virus is also transmitted during unprotected
contact with VHF infectious body fluids


OR


contaminated medical equipment and supplies


OR


as a result of an accidental needlestick or
accidental exposure to infectious body fluids.


The exposed person carries the virus back to the
community. Transmission continues if there is


direct person-to-person contact OR any
unprotected contact with infectious body fluids.


4




Introduction


What Is in This Manual


This manual describes a system for using VHF Isolation
Precautions to reduce the risk of transmission of VHF in the health
care setting. The VHF Isolation Precautions described in the
manual make use of common low-cost supplies, such as
household bleach, water, cotton cloth, and plastic sheeting.
Although the information and recommendations are intended for
health facilities in rural areas in the developing world, they are
appropriate for any health facility with limited resources.


Who the Manual Is For


The manual is intended primarily for health officers who
implement infection control in the health care setting, and for:


• Health facility administrators


• Hospital outbreak coordinators


• Chief medical officers


• Chief nursing officers


• Medical and nursing staff


• Medical and nursing educators


• Public health officers and programme administrators.


Objectives


The information in this manual will help health facility staff to:


1. Understand what VHF Isolation Precautions are and how to
use them to prevent secondary transmission of VHF in the
health facility.


2. Know when to begin using VHF Isolation Precautions in the
health care setting.


3. Apply VHF Isolation Precautions in a large-scale outbreak.
(When a VHF occurs, initially as many as 10 cases may
appear at the same time in the health facility.)


5




4. Make advance preparations for implementing VHF Isolation
Precautions.


5. Identify practical, low-cost solutions when recommended
supplies for VHF Isolation Precautions are not available or
are in limited supply.


6. Stimulate creative thinking about implementing VHF
Isolation Precautions in an emergency situation.


7. Know how to mobilize community resources and conduct
community education.


How to Use the Manual


This manual can be used as a rapid reference when one or two
cases of a VHF appear in a health facility and no previous
preparations for VHF Isolation Precautions have been done.
Administrators or hospital outbreak coordinators can use the
information and instructions to set up an isolation area quickly and
make adaptations from local materials so that an effective system
of infection control can be implemented as soon as possible.


The manual can also be used for planning and carrying out
in-service training aimed at strengthening VHF Isolation
Precautions. It can be accompanied by workshop activities, in
which participants discuss and practice the recommendations
made in this manual.


The manual should be used to help health facilities make advance
preparations for responding with appropriate precautions when a
VHF case is suspected.


6




Introduction


This manual consists of nine sections:


Section 1 Use Standard Precautions with All Patients describes how to establish
routine precautions for infection control. The section emphasizes the
importance of using Standard Precautions consistently, especially
handwashing before and after examining patients with fever.


Section 2 Identify Suspected Cases of VHF lists common signs and symptoms of
VHF and the immediate precautions to take when a VHF is suspected.


Section 3 Isolate the Patient lists recommended supplies and describes how to set
up an isolation area. It includes checklists that can be used in an
emergency situation and practical suggestions for alternate equipment
when recommended items are not available.


Section 4 Wear Protective Clothing describes the protective clothing that should be
worn when VHF is present in the health facility. It also provides
information about selecting appropriate items when recommended
clothing is not available.


Section 5 Disinfect Reusable Supplies and Equipment describes the use of VHF
Isolation Precautions during patient care and when disinfecting and
cleaning contaminated surfaces, supplies and equipment. This section
also presents recommended first aid for accidental exposures.


Section 6 Dispose of Waste Safely describes step-by-step procedures for disposing
of VHF-contaminated waste. It also lists detailed instructions for building
an incinerator from available material.


Section 7 Use Safe Burial Practices describes how to prepare bodies of deceased
VHF patients safely for burial and how to prevent disease transmission
through contact with the deceased patient.


Section 8 Mobilize the Community and Conduct Community Education provides
guidance for involving the community in disease prevention and control
activities when VHF is suspected. It also describes how to choose a VHF
Coordinator.


Section 9 Make Advanced Preparations to Use VHF Isolation Precautions lists
steps for preparing in advance to use VHF Isolation Precautions. If
advance preparations have been carried out, and a VHF is suspected, the
supplies are ready and health facility staff are trained in recommended
practices. When advance preparations are not possible, VHF Isolation
Precautions must be implemented in an emergency situation.


The Annexes provide additional details about specific topics described in the manual.


7




Glossary for Use with This Manual


Changing room Area next to isolation ward where health workers dress in protective
clothing, disinfect hands and gloves, and dispose of soiled and
contaminated protective clothing.


Cleaning Removal of any soiling or other material on equipment or surfaces
before disinfection or sterilization.


Contamination Presence of infectious agent in blood and other body fluids, on body
surfaces and medical equipment, clothing and supplies. Contact with
contaminated body fluids or items is a risk for disease transmission.


Disinfection Elimination of most microorganisms from a surface, making it safe for
reuse. “Sterilization” means eliminating all microorganisms.


Health care worker Any person trained to provide patient care (medical, nursing,
paramedical, emergency room nurses, community health workers).


Health facility Any hospital, health centre or clinic with inpatient facilities. Also any
facility providing emergency or first-service care.


Health facility staff All patient care, laboratory, cleaning, disposal, reception, and
administrative staff who are likely to have contact with suspected VHF
cases, VHF infectious body fluids, and infectious waste.


Isolation area/ward The area in the health facility used for housing suspected VHF
patients. It includes the patient's room or area, isolated latrine or
toilet, family entrance, and changing room.


Protective clothing Masks, gloves, gowns, eyeglasses, caps, aprons, and boots. Provides
protection against splashes or spills of infectious material when
examining suspected VHF cases or handling infectious waste and
laundry.


Sharps container Puncture-resistant container for collecting used needles and syringes.


Standard Precautions Practices for limiting or preventing disease transmission in the health
care setting.


Sterilization Elimination of all microorganisms (viral, bacteria, and fungal) through
heat, using an autoclave or steam sterilizer, or other appropriate
methods.


VHF Coordinator Designated health officer who coordinates infection control and
outbreak response, and provides liaison with the community and other
agencies involved in outbreak control.


VHF Isolation Barrier nursing and other infection control practices for preventing
Precautions contact between VHF infectious body fluids and non-infected persons.


8




Section 1


Use Standard Precautions with
All Patients


This section describes how to:


• Identify a minimum level of Standard Precautions for use
with all patients regardless of their infection status.


• Establish routine handwashing practices.


• Establish safe handling and disposal of used needles and
syringes.


• Be prepared to intensify Standard Precautions and include
VHF Isolation Precautions.


• Identify a VHF Coordinator to oversee and coordinate
activities associated with VHF Isolation Precautions.




Section 1


10




Section 1 Use Standard Precautions with All Patients


1.1 Use Standard Precautions


Health workers throughout the world are aware of the risks for
transmitting human immunodeficiency virus (HIV) and hepatitis
viruses in the health care setting. Many use precautions (such as
wearing gloves) for preventing contact with infected blood.


Other dangerous diseases are also transmitted through contact with
blood or other body fluids and pose a significant risk in the health
care setting. For instance, a patient with a VHF may come to the
health facility at any point in his or her illness,


• When the possibility of exposure is often highest, and


• Before the specific cause of the patient’s illness is known.


Because a health worker cannot always know when a patient’s
body fluids are infectious, Standard Precautions2 should be used
with all patients in the health care setting, regardless of their
infection status.


Standard Precautions are designed to prevent unprotected contact
between the health care worker and


• Blood and all body fluids whether or not they contain
blood


• Mucous membranes.


When a specific diagnosis is made, additional precautions are
taken, based on how the disease is transmitted.3


2 See Annex 1 for more information about Standard Precautions.


3 This manual describes the Isolation Precautions to use when a patient is known to have or suspected of
having a VHF. Annex 1 describes other precautions for various modes of disease transmission.


11




Section 1


1.2 Establish and Maintain a Minimum Level of
Standard Precautions


Limited supplies and resources may prevent a health facility from
using all the Standard Precautions all the time. However, health
facilities should establish and maintain a basic, practical level of
Standard Precautions that can be used routinely with patients in
their health facility.


At a minimum, consider the services in the health facility that
present a risk of disease transmission due to potential contact with
blood and all body fluids, broken skin or mucous membranes.


For health facility staff who work in such areas, establish at least:


• A source of clean water (Please see Annex 7)


• Routine handwashing before and after any contact with a
patient who has fever


• Safe handling and disposal of sharp instruments and
equipment, including needles and syringes.


1.3 Establish Routine Handwashing


Handwashing is the most important precaution for the


prevention of infections.


Handwashing before and after contact with a patient who has fever
should be a routine practice in the health facility — even when
VHF is not present. Washing hands with soap and water
eliminates microorganisms from the skin and hands. This provides
some protection against transmission of VHF and other diseases.


In services where health care workers see patients with fever,
provide at least:


• Cake soap cut into small pieces


• Soap dishes. Microorganisms grow and multiply in
humidity and standing water. If cake soap is used, provide
soap dishes with openings that allow water to drain away.


• Running water, or a bucket kept full with clean water


12




Use Standard Precautions with All Patients


• A bucket for collecting rinse water and a ladle for dipping,
if running water is not available


• One-use towels. Sharing towels can result in
contamination. Use paper towels. If they are not available,
provide cloth towels that can be used once and then
laundered. If towels are not available, health care workers
and health facility staff can air-dry their hands.


Fig. 2. An example of a handwashing station


Make sure health facility staff know the steps of handwashing:


1. Place a piece of soap in the palm of one hand.


2. Wash the opposite hand and forearm. Rub the surfaces
vigorously for at least 10 seconds. Move soap to the
opposite hand and repeat.


3. Use clean water to rinse both hands and then the forearms.
If running water is not available, pour clean water from a
bucket over the soapy hands and forearms. The rinse water
should drain into
another bucket.


4. Dry the hands and
forearms with a clean,
one-use towel. First
dry the hands and then


Back


the forearms. Or let
rinsed hands and
forearms air-dry.


Front


Fig. 3. The shading shows the parts of hands that are
often missed during handwashing. Make sure to wash
all parts of your hands: front, back, between the
fingers and under nails.


13




Section 1


1.4 Handle and Dispose of Sharp Instruments Safely


Disease transmission can occur through accidental needlestick
injuries. Make sure health facility staff always handle sharp
instruments safely. Do not recap needles after use.


Limit invasive procedures to reduce the number of injectable
medications. This will limit the opportunities for accidental
needlestick injuries.


When an injection is necessary, always
use a sterile needle and sterile syringe
for each injection.


To discard disposable needles and


syringes safely: Disposable needles
and syringes should be used only once.
Discard the used disposable needle
and syringe in a puncture-resistant
container. Then burn the container in
an incinerator or pit for burning.


Instructions for using incinerators and
pits for burning are described in
Section 6.


If puncture-resistant containers are not
available, use empty water, oil, or
bleach bottles made with plastic or
other burnable material. Adapt them
for use as puncture-resistant
containers.


Detailed instructions for making a
puncture-resistant container are listed
in Annex 9.


Fig. 4. Standard sharps container


Fig. 5. Using plastic bottle to
dispose of used needles


14




Use Standard Precautions with All Patients


1.5 Disinfect Reusable Needles and Syringes Safely


Reusable needles and syringes are not recommended. If reusable
needles and syringes are used, clean, disinfect and sterilize them
before reuse, according to your hospital’s policy.


Note: Needles and syringes used with VHF patients require
special care. Cleaning staff should wear two pairs of gloves when
handling needles and syringes used with any patient with a known
or suspected VHF. See the recommendations for wearing
protective clothing when handling contaminated supplies in
Section 4.


1.6 Disinfect Disposable Needles and Syringes That
Must Be Reused


Remember! Whenever possible, use disposable needles and


syringes only once and then discard them safely.


In situations when disposable needles and syringes must be
reused, make sure they are cleaned and disinfected after each use.
Disinfection with bleach will reduce the risk of transmission of
VHF and blood-borne diseases, such as HIV infection and viral
hepatitis.


1. Obtain a jar or pan. Clean and disinfect it. Use it in Step 8
to store the disinfected needles and syringes.


2. Place the disposable
needle and syringe in a
pan of soapy water after
use. Fill the needle and
syringe with soapy water.
Leave them to soak until
they are cleaned.


3. Take the soaking needles
and syringes to the
cleaning area.


4. Clean them very carefully
in soap and water.
Remove any blood or
other biological waste, especially from the area around the
syringe fittings. Blood or other biological products may
collect in these small openings.


15


Fig. 6. Placing the disposable needle
and syringe in soapy water




Section 1


5. Draw full-strength bleach into the needle and syringe.


6. Soak for 30 seconds, and then expel bleach into a container
for contaminated waste.


7. Soak again by once more drawing full-strength bleach into
the needle and syringe. Soak for 30 seconds, and then
expel bleach into the container for contaminated waste.


8. Let the disinfected needle and syringe air-dry. Store them
in a clean jar or pan that has been disinfected.


1.7 Use VHF Isolation Precautions


Section 2 of this manual describes how to identify a suspected case
of VHF so that relevant health facility staff can begin using VHF
Isolation Precautions. When a VHF is suspected, those health
facility staff who will have contact with the patient or with the
patient’s blood or other body fluids should intensify Standard
Precautions and use VHF Isolation Precautions.


VHF Isolation Precautions: The VHF Isolation Precautions
described in this manual have been shown to be effective in
reducing the transmission of VHFs in the health care setting.


As soon as a case of VHF is suspected in the health facility, alert
authorities and start VHF Isolation Precautions.


16




Use Standard Precautions with All Patients


To reduce the risk of VHF transmission in a health care
setting:


USE VHF ISOLATION PRECAUTIONS


1. Isolate the patient.


2. Wear protective clothing in the isolation area, in the
cleaning and laundry areas and in the laboratory.
Wear a scrub suit, gown, apron, two pairs of gloves,
mask, headcover, eyewear, and rubber boots.


3. Clean and disinfect spills, waste, and reusable
equipment safely.


4. Clean and disinfect soiled linens and laundry safely.


5. Use safe disposal methods for non-reusable supplies
and infectious waste.


6. Provide information about the risk of VHF
transmission to health facility staff. Reinforce use of
VHF Isolation Precautions with all health facility staff.


7. Provide information to families and the community
about prevention of VHFs and care of patients.


Regular in-service training will strengthen skills for using VHF
Isolation Precautions. When a VHF is suspected, efforts will have
to be focused on providing care. There will not be enough time or
opportunity to provide initial training in skills for VHF Isolation
Precautions.


If health facility staff already know how to use VHF Isolation
Precautions when a VHF is suspected, authorities can be alerted
and VHF Isolation Precautions started without delay.


If health facility staff do not know how to use VHF Isolation
Precautions when a VHF case is suspected, training will need to
take place immediately.


17




Section 1


1.8 Select a VHF Coordinator


Being prepared for an emergency situation can save lives. In
addition to using a basic level of Standard Precautions with all
patients, health facilities can also prepare in advance for situations
when protective clothing, disinfection materials, and isolation
procedures are needed urgently.


Many health facilities already have an emergency coordinator or
emergency team who could assume the role of a “VHF
Coordinator.” The “VHF Coordinator” will:


• Oversee advance preparations and ensure that health
facility staff are prepared to use VHF Isolation Precautions.


• Serve as the focal point and coordinate activities when a
VHF case is suspected.


• Take the lead in mobilizing the community when an urgent
situation occurs.


Once a staff person is identified to serve as the VHF Coordinator,
he or she can review the recommendations in this manual and
begin the preparations described in Section 9. The VHF
Coordinator can also encourage efforts to strengthen and reinforce
the routine practice of a basic level of Standard Precautions with
all patients.


Remember! Using a minimum level of Standard Precautions


routinely will prevent transmission of contagious diseases, such


as HIV infection, viral hepatitis and VHF.


18




Section 2


Identify Suspected Cases of VHF


This section describes how to:


• In a non-outbreak situation, suspect VHF in patients with
fever, severe illness, and signs of unexplained bleeding.


• Alert relevant health facility staff and begin VHF Isolation
Precautions as soon as VHF is suspected.


• Report the suspected case to designated health authorities.




Section 2


20




Section 2 Identify Suspected Cases of VHF


In an outbreak situation, several cases occur around the same time.
They may be grouped together, and there may be person-to-person
transmission. An initial diagnosis of a VHF can be made based on
the signs and symptoms of the specific VHF.


Suspecting a VHF during a non-outbreak situation in a single case
is more difficult. The early symptoms of a VHF include high fever
and headache. These are also symptoms for many infections seen
at the health facility.


Most patients who present with fever do not have a VHF. Their
fever is more often caused by malaria, typhoid fever, dysentery,
severe bacterial infection or other fever-producing illnesses usually
seen in the area.


The health worker probably will not suspect a VHF until more
severe signs develop and the patient does not respond to
recommended treatment for other illnesses.


However, health workers should be aware of the possibility for
suspecting a VHF in a non-outbreak situation. As soon as a VHF is
suspected, VHF Isolation Precautions should begin. This will help
reduce the number of people exposed to the VHF.


21




Section 2


2.1 Use Information from Previous Outbreaks to
Suspect a VHF


When a patient presents with fever, use the available diagnostic
tools in your health facility to identify or exclude the cause of
fever. For example, do a malaria smear or take a stool culture as
soon as possible.


• Treat the most likely cause of the fever according to the
appropriate treatment guidelines.


• If the fever continues after 3 days of recommended
treatment, and if the patient has signs such as bleeding or
shock, consider a VHF.


• Review the patient’s history for any contact with someone
who was ill with fever and bleeding or who died from an
unexplained illness with fever and bleeding.


• If no other cause is found for the patient’s signs and
symptoms, suspect a VHF. Begin VHF Isolation
Precautions.


The flowchart on the next page shows how to


• Suspect a VHF and


• Decide to use VHF Isolation Precautions.


The flowchart applies to a non-outbreak situation. Annex 4 gives
examples of VHF case definitions in outbreak situations.


22




Identify Suspected Cases of VHF


Use Isolation Precautions for Suspected VHF Cases


• Severe illness with weakness and
fatigue


• Measured fever (38.5oC or 101oF)
for more than 72 hours and less
than 2 weeks


Diagnose and treat for likely cause of


fever in area (such as malaria,


typhoid fever, dysentery, severe


bacterial infection)


If no response to


antimalarial and


antibiotic treatment


Does patient have one or more of the following?


* Unexplained bleeding from


– mucous membranes (gum, nose or vagina)


– skin (puncture sites, petechiae)


– conjunctiva (red eyes due to swollen blood
vessels)


– gastrointestinal system (vomiting blood; dark
or bloody stools)


* Shock: blood pressure <90mm Hg or rapid,
weak pulse


* Contact in the 3 weeks prior to onset of illness
with anyone who had an unexplained illness
with fever and bleeding or who died after an
unexplained severe illness with fever


Suspect a VHF


and


Begin VHF Isolation Precautions


23




Section 2


If VHFs have occurred in the area before:


Talk with the district or national surveillance officer about VHFs
that have been reported in your area.4 Use the information when
making a diagnosis of a suspected VHF case.


Record here the case definitions for VHFs that have been reported
in your area:


VHF Case Definition


4 Annex 2 provides more information about VHFs seen in the area of your health facility.


24




Identify Suspected Cases of VHF


2.2 Begin VHF Isolation Precautions


Every health facility has its own procedures for responding to an
urgent situation. Adapt VHF Isolation Precautions as needed.
Designate the health officer who will coordinate VHF Isolation
Precautions. How to select a VHF Coordinator is described in
Section 9.1. As soon as a health care worker suspects a VHF, he
or she should notify the health facility administrator and the VHF
Coordinator who will:


• Refer the patient to the isolation area and take the necessary
steps to begin VHF Isolation Precautions (See Section 3).


• Limit the number of health facility staff and visitors in the
patient’s room.


• Limit the use of invasive procedures and reduce the number
of injectable medications.


Important! Between the time when VHF is suspected and when
the patient is received in the isolation area, there is a risk for
disease transmission from the patient’s blood and other body fluids
(stool, urine, vomit). Prevent disease transmission to other
patients, visitors and health staff in the waiting area by placing the
suspected VHF patient apart from other patients. Make every effort
to reduce this waiting time.


2.3 Alert Health Facility Staff about Specific Risks for
VHF Transmission


As soon as a VHF is suspected, alert the relevant health staff who
should begin using VHF Isolation Precautions, especially:


• Doctors or nurses providing direct patient care


• Cleaning, laundry, and waste disposal staff who clean and
disinfect contaminated material and supplies


• Laboratory staff who handle samples from the suspected
VHF cases


• Medical or support staff who prepare or handle deceased
VHF patients.


25




Section 2


Explain how VHF transmission can occur in the health facility and
the risks to health facility staff.5 Remind the staff that VHF is a
highly infectious disease. They must use VHF Isolation
Precautions whenever they have contact with the VHF patient, the
patient’s blood or other body fluids, or contaminated supplies and
equipment.


Fig. 7. An example of VHF Isolation Precautions poster.


5 The chart on page 4 of the Introduction summarizes the risk of VHF transmission in the health care
setting.


26




Identify Suspected Cases of VHF


2.4 Report the Suspected Case to the Health
Authorities


Report suspected cases of VHF according to national level
surveillance guidelines.


If your district is conducting special surveillance activities for a
VHF, the district officer will provide specific information about
whom you should contact and how. If serum samples are needed,
the contact person will give you special instructions for collecting
and shipping serum samples. The table below can be used to
record information about whom to contact if a VHF is suspected.


Contact
Person


Agency
Telephone
and/or Fax
Number


Information to
Report


Samples
to


Collect


27




Section 2


2.5 Identify Patient’s Contacts and Travel History


Ask the patient (or a family member who can answer for the
patient):


• Where do you live?


• When did the symptoms begin?


• Who else is sick in your family (or village)?


• Where have you travelled recently?


Use the answers to identify others who had contact with the
patient. Provide them with information about VHF and when to
seek care.


Section 8 describes the steps for giving information to the
community about VHF and preventing VHF transmission.


28




Section 3


Isolate the Patient


This section describes how to:


• Gather supplies to set up an isolation area.


• Make a substitute item from available materials whenever a
recommended item is not available.


• Select a site for the VHF isolation area and set up:


— The patient’s room


— A changing room for health care workers to use
when changing clothes


— A changing room for other health facility staff to use
near their work area


— A family entrance, if necessary


— A security barrier around the entire isolation area.


• Counsel family members about patient care.




Section 3


30




Section 3 Isolate The Patient


Isolating the VHF patient will:


• Restrict patient access to health facility staff trained to use
VHF Isolation Precautions.


• Establish a barrier between the VHF patient and uninfected
patients, other health facility staff, and visitors.


3.1 Select Site for the Isolation Area


Ideally, an isolation area should already be available to admit
patients requiring isolation.


If an isolation area is not available or if advance preparations have
not been done, and VHF is suspected, immediately identify and set
aside:


• A single room with an adjoining toilet or latrine.


If a single room is not available, select one of the following in
order of preference:


• A separate building or ward that can be used with VHF
patients only (especially if Ebola haemorrhagic fever is
suspected, or if there is a large number of patients)


• An area in a larger ward that is separate and far away from
other patients in the ward


• An uncrowded corner of a large room or hall


• Any area that can be separated from the rest of the health
facility (TB rooms, isolation ward for infectious diseases,
private or semiprivate rooms).


31




Section 3


Make sure the selected site has:


1. An isolated toilet: If a toilet is not next to the patient's
room, select and isolate a toilet near the isolation area. Use
it to receive the patient’s disinfected waste and other liquid
waste.


If a toilet is not available, prepare a latrine for disposal of
the patient’s and other liquid waste.


2. Adequate ventilation: The isolation room should have
adequate ventilation because chlorine disinfectants will be
used. To prevent airborne or droplet transmission of
infectious agents, avoid rooms with air conditioning.


3. Screened windows: If windows are left open for cooling,
screen them to prevent transmission of mosquito- and other
insect-borne diseases.


Restrict access. Tie a rope or line around the area outside the
window to restrict the area and prevent entry through the window.


3.2 Plan How to Arrange the Isolation Area


Make use of the available space and design of the health facility to
arrange the isolation area. The diagram below shows an ideal
arrangement for an isolation area. The next page shows examples
for a single patient’s room and for a ward with several patients.


Patient’s room Toilet


Changing room
12


11 1


10 2


9 3


8 4


7 5
6


Fig. 8. A sample layout of an isolation area


32




Isolate the Patient


Toilet Patient’s room Changing room


Bed


Bedside
table


Storage
shelf


Disinfection


station


Disinfection station Disinfection station


Hooks


Storage
shelf


Fig. 9. A sample layout for a single patient


Screens between beds
Disinfection station


Bed Bed


Bed Bed Bed


Toilet


Bed


Changing room


Disinfection station


Hooks


Storage
shelf


Storage
shelf


Table for medical supplies and equipment;


disinfection and handwashing stations


Fig. 10. A sample layout for several patients


33




Section 3


3.3 Gather Recommended Supplies


Ideally, supplies should be available to begin VHF Isolation
Precautions. If a separate emergency supply is not available when
a VHF case is suspected, use supplies from other services in the
health facility.


If a recommended item is not available, or if the quantity is
limited, make a substitute item from available materials. For
example, the manual recommends using plastic sheeting to cover
mattresses. If plastic sheeting is not available, use plastic cloth
normally used to cover kitchen tables. This is usually available in
the local market.


3.3.1 Plan Disinfection for VHF-Contaminated Items


Ordinary household bleach, soap and water are useful
disinfectants against viruses causing VHF.6 They are low in cost
and commonly available.


Ordinary Household Bleach: The viruses causing VHF are
very sensitive to bleach solution. This manual describes a
low-cost disinfection system using two bleach solutions: a
solution of 1:10 and a solution of 1:100. Detailed
instructions for preparing the solutions are in Section 5.1.


Soap and Clean Water: Scrubbing with soap and water
before disinfection removes infectious body fluids and other
foreign matter from contaminated items. This makes bleach
solutions more effective. Detailed instructions for preparing
solutions of soapy water are in Section 5.2.


Sterilization: Heat sterilization requires special equipment,
such as an autoclave or steam sterilizer. When this
equipment is not working or is not available, boiling
heat-resilient items in water for 20 minutes will kill VHF
viruses.


6 VHF viruses are lipid enveloped, and this feature makes them sensitive to destruction by detergent
solutions.


34




Isolate the Patient


3.3.2 Gather Supplies for the Patient Area


Obtain the following items for use in the patient’s room:


Bed and mattress or sleeping mat for each patient.


Plastic sheeting to cover the mattress or sleeping mat. This is strongly
recommended. Plastic sheeting will protect the mattress from contamination. It
can be easily cleaned and disinfected if it becomes contaminated with infectious
body fluids.


Bedding for each bed -- at least 1 blanket and a bottom sheet. If necessary, the
patient or the patient's family can bring the bedding from home.


One thermometer, one stethoscope, and one blood-pressure cuff per patient.
Keep them in the isolation area for reuse with the same patient.


If there is not enough equipment to supply one each of these items per patient,
assign one piece of equipment for use only with the patients in the isolation area.


Covered container for alcohol or bleach solution used to disinfect thermometer
and stethoscope after use with each patient.


Puncture-resistant container for collecting used disposable needles, syringes and
other sharp instruments.


Puncture-resistant tray with soapy water for collecting reusable needles,
syringes and instruments.


Bedside table or shelf on which to place medical instruments, puncture-resistant
container, and so on.


Large wall clock with a second hand for measuring respiration rates and pulse.


Bedpan for each patient.


Screens or other barriers to place around the VHF patients' beds. This will
prevent patient-to-patient transmission through spills or splashes of infectious
body fluids or from aerosol routes.


If screens are not available, stretch ropes or lines from one end of the patient
area to the other. Hang sheets from the ropes.


Disinfection station with buckets, sprayer, bleach solutions, soap and water,
mop, and a supply of one-use towels. It is preferable to dispose of gloves after
each use. However, the reuse of gloves in many health facilities is a common
practice. Disinfect gloved hands between patients if there are not enough gloves
for health care workers to dispose of after each patient.


Container with soapy water for collecting discarded outer gloves.


35




Section 3


Boot sprayer for disinfecting the boots before leaving the patient’s room.


Extra supply of gowns and gloves.


3.3.3 Gather Supplies for the Changing Room


Hooks, nails, or hangers for hanging reusable protective clothing.


Roll of plastic tape for taping cuffs and trousers of protective clothing.


Disinfection station with bleach solution for disinfecting gloved hands.


Handwashing station with bucket, soap, soap dish, clean water, and supply of
one-use towels.


Containers with soapy water for collecting:


• Discarded gloves


• Used instruments to be sterilized.


Containers for collecting:


• Reusable protective clothing to be laundered


• Infectious waste to be burned.


3.3.4 Arrange for Storing of Supplies Outside the Changing Room


Shelf or box with a lock for storing clean protective clothing.


Supply of clean protective clothing.


Container for collecting non-infectious waste.


Covered shelf (or plastic bags which can be closed) to store disinfected boots
and keep them dry.


The checklists at the end of this section can be used to gather supplies for the isolation
area.


36




Isolate the Patient


3.4 Set Up Changing Rooms


For patient-care staff:


One changing room is needed outside the patient isolation area.
This area is where health care workers will put on protective
clothing to protect them from spills or splashes of infectious body
fluids while they are in the patient’s room. After leaving the
patient's room, they will reenter the changing room and remove
the protective clothing. They will hang it for reuse or dispose of it
appropriately.


Contaminated clothing and supplies remain in the changing room
until cleaning staff trained to use VHF Isolation Precautions take
the VHF-contaminated items to the laundry or disposal site.


For laboratory, cleaning, laundry, and waste disposal staff:


Set up changing rooms near the work areas for other health facility
staff who will handle laboratory specimens and who will clean
launder, or dispose of contaminated items. They will also need to
wear protective clothing during any contact they have with body
fluids or VHF-contaminated items.


The stations in the changing room should be set up so that traffic
flow is from the least to most contaminated area.


3.5 Place Security Barrier Around Isolation Area


Restrict access to the isolation


area: Place signs around the
isolation area clearly stating
that access is restricted. Or tie
lines or ropes around the
isolation area and hang plastic
sheets from them.


Fig. 11. A security barrier and sign


37




Section 3


Prepare a list of health facility staff and family members


authorized to enter the isolation area: List the medical, nursing,
laboratory, cleaning staff, and, if appropriate, those family
members who are trained in the use of VHF Isolation
Precautions. If an accidental exposure or incident occurs, the list
can help in the prompt identification of possible contacts.


When there is a large number of patients, station a guard at the


entry to the isolation area: In a large scale outbreak, station a
security guard at the door of the patient isolation area outside the
changing room. The guard will limit access to authorized health
facility staff and family members only. This is critical for
maintaining strict isolation and protecting the community.


Provide the guard with the list of authorized persons and a sign-in
sheet. The guard can record who comes into the isolation area
and note the time of entry and departure.


Date Name Service Time In Time Out


13.6.98 Dr. Nsango
Infectious
Diseases


10:15 11:30


13.6.98
Nurse


Bandari
Intensive


Care
10:00 11:30


13.6.98
Nurse


Ninakazi
Intensive


Care
11:00 13:30


13.6.98 Masika Cleaning 11:10 11:45


13.6.98 Madunda
Family
member 11:15


Fig. 12. An example of a sign-in sheet


38




Isolate the Patient


3.6 Consult Family Members about Patient Care


Talk with family members and explain why the patient is being
isolated. Tell them about the risk of transmission for VHF and why
protective clothing is needed. Answer any questions they have.


When there is a large outbreak (more than one or two cases),
identify a person to serve as a liaison between health facility staff
and the patients’ families. Select a health staff member, an
experienced community member, or a convalescent patient.


If it is the custom for family members to provide cleaning and
washing of the patient while the patient is in the health facility,
help the family to select a caregiver. Select as caregiver the family
member who has already had the most contact with the patient.
Also select a second person who can do the patient care activities
when the other caregiver is resting.


In areas where family members participate in patient care, they are
likely to help the patient with:


• Feeding and giving water


• Washing the hospital gown or pyjama with soap and water


• Getting up or moving around.


When a VHF is suspected, it is likely that health care workers
trained in VHF Isolation Precautions will do most of the direct
patient care tasks. However, if there are family members who will
assist with direct patient care, give them information and training
about:


• The risk of VHF transmission and the reason for protective
clothing


• How to wear gloves, gowns, and a mask


• How to take off gloves, gowns, and mask and store or
dispose of them safely.


Make sure there is a changing room for family members to use that
is separate from the changing room for health care workers.
Provide a set of protective clothing for the family members to wear
in the isolation room. At a minimum, make sure that the family
members wear at least a pair of gloves.


39




Section 3


Provide in the family members’ changing room:


• A shelf or table to store a supply of clean gloves to be worn
by the family member


• Hooks to hang a set of protective clothing


• A bucket with soapy water for collecting discarded gloves
after leaving the isolation area


• A handwashing station.


Arrange to monitor family members for signs of illness.


Assist family members with:


• Coordination of other family members who bring food for
the patient and for the family member providing care


• Location of an area for family members to stay in while
providing care that includes cooking, washing and sleeping
facilities.


Note: When a breast-feeding mother has a suspected case of VHF,
the child's breast-feeding should not be interrupted. Help the
family to decide how to continue the child’s breast-feeding when
the mother is too ill to do so.


40




Isolate the Patient


Checklist: Supplies for a Changing Room


Storage Outside the Changing Room:


1. Shelf or cabinet with lock


2. Supply of clean scrub suits, gowns, aprons,
gloves, masks, headcovering, and eyewear


3. Covered shelf for storing disinfected boots


4. Bucket for collecting non-infectious waste


Inside the Changing Room:


1. Hooks, nails, or hangers for hanging reusable
gowns, scrub suits


2. Roll of plastic tape


3. Handwashing supplies: bucket or pan, clean
water, soap, one-use towels


4. Bucket or pan, 1:100 bleach solution for
disinfecting gloved hands


5. Container with soapy water for collecting
discarded gloves


6. Container with soapy water for collecting used
instruments to be sterilized*


7. Container with soapy water for collecting
reusable gowns, masks, sheets to launder*


*Place outside the changing room if the changing room
is too small


If large amounts of waste on floor:


Sprayer, bucket or shallow pan with 1:100 bleach
solution for disinfecting boots


41




Section 3


Checklist: Supplies for Patient Area


1. 1 bed with clean mattress or sleeping mat and at
least a bottom sheet and blanket for each bed


2. Plastic sheeting to cover mattress or sleeping mat


3. 1 thermometer, 1 stethoscope, and 1 blood
pressure cuff for each patient or for each patient
area


4. 1 puncture-resistant container for collecting
non-reusable needles, syringes, and discarded
sharp instruments


5. 1 bedside table or shelf


6. 1 large wall clock with a second hand


7. Pan with 1:100 bleach solution or alcohol and
one-use towels for disinfecting the thermometer
and stethoscope between use with each patient


8. Bucket or pan, 1:100 bleach solution, one-use
towels for disinfecting gloved hands between
patients


9. Supplies for disinfecting patient excreta (bedpan,
urinal, 1:10 bleach solution)


10. Sprayer, 1:100 bleach solution, clear water, and
mop for disinfecting spills on floor and walls


11. Container with soapy water for collecting
discarded gloves


12. Screens (or sheets hung from ropes or lines)
placed between VHF patients’ beds


13. Extra supply of gowns and gloves


14. Container for collecting infectious waste to be
burned


42




Section 4


Wear Protective Clothing


This section describes how to:


• Prepare a supply of protective clothing for use with VHF
Isolation Precautions.


• Make adaptations from locally available materials when an
item is not available, or if the supply is limited.


• Put on and take off protective clothing in the changing
room.




Section 4


44




Section 4 Wear Protective Clothing


4.1 Specify Who Should Wear Protective Clothing


• All doctors, nurses, and health care workers who provide
direct patient care to suspected VHF patients.


• All support staff who clean the isolation room, handle
contaminated supplies and equipment, launder reusable
supplies, and collect and dispose of infectious waste from
VHF patients.


• All laboratory staff who handle patient specimens and body
fluids from suspected VHF cases.


• Laboratory support staff who clean and disinfect laboratory
equipment used to test VHF specimens.


• Burial teams who remove bodies of deceased VHF patients
and prepare them for burial.


• Family members who care for VHF patients.


When a VHF case is suspected in the health facility, the following
protective clothing should be worn in the isolation area:


• A scrub suit or inner layer of clothing (an old shirt and
trousers brought from home)


• A pair of thin gloves


• Rubber boots or overshoes (only if the floor is soiled)


• A gown or outer layer of clothing (surgical or disposable
gown with long sleeves and cuffs)


• A plastic apron worn over both layers of clothes


• A second pair of thin or thick gloves. Wearing a second
pair of gloves provides an added measure of safety during
patient care and when handling contaminated supplies


• A HEPA-filter (high-efficiency particulate air respirator) or
other biosafety mask (or surgical mask if HEPA-filter or
other biosafety mask is not available)


45




Section 4


• Cotton head covering


• Clear eyeglasses or non-fogging goggles.


Note: When protective clothing is not available or is in short


supply, adaptations must be made and used.


4.2 Gather a Supply of Protective Clothing


Obtain and store the following items
outside the changing room or in a
storage cabinet inside the changing
room.


Scrub suit or inner layer: Wear a
scrub suit or a set of old clothes
brought from home (such as a
loose-fitting shirt and trousers).
Avoid wearing long skirts to prevent
contact between clothing and spills
of infectious waste on the floor.


Thin gloves: These permit
fine-motor function when
examining or caring for patients.
They can be latex, vinyl, or
surgical gloves; they do not need
to be sterile. The gloves must
reach well above the wrist,
preferably 10 cm to 15 cm long (4
inches to 6 inches), measuring
from the wrist up along the arm.


46


Fig. 13. Inner layer of clothing


Fig. 14. Thin gloves




Wear Protective Clothing


Boots: Boots or overboots must be worn over street shoes when
infectious waste is on the floor. Common rubber boots are
recommended. The sides of the boots should be at least 30 cm
(12 inches) high and have textured soles.


If boots are not available, wear two layers of plastic bags.


Fig. 15. Using plastic bags as boots


Assign those staff who are entering the isolation area their own
pairs of boots. Staff members will be responsible for storing their
boots in a covered shelf or in a plastic sack between each use.


Fig. 16. Storing boots


Gown or Outer Layer: Wear a disposable surgical gown or a
cotton gown over the first layer of clothes.


Disposable surgical gowns can be reused by the same staff
member if they are not contaminated and are not obviously dirty
and torn.


When the supply of disposable gowns is limited, wear a cotton
surgical gown that can be washed and reused.


47




Section 4


The gown should:


• Open at the back and close with ties at the neck and waist.


• Be knee-length with collar wraps around the neck and
elastic bands to close the gown around the wrist. If elastic
bands are not used, sew on cotton loops. They can be
hooked around the thumb to hold the sleeve in place.


front back


Fig. 17. Illustration of gown with ties


If the supply of cotton surgical gowns is limited, make additional
gowns from local cotton fabric. Instructions for making cotton
gowns are listed in Annex 5. Specifications for ordering gowns
and other pieces of recommended clothing are listed in Annex 6.


Plastic Aprons: Wear a plastic apron over the outer gown. The
apron prevents contact with infectious body fluids that may soak
through protective clothing when the
patient bleeds, coughs or vomits.


Plastic aprons should be worn by
anyone who has direct contact with a
suspected VHF case or infectious
body fluids. These aprons are strongly
recommended for:


• Nurses


• Laboratory staff


• Cleaning staff


• Staff who perform autopsies or
prepare bodies for burial.


Fig. 18. Wearing a plastic apron


48




Wear Protective Clothing


When a supply of commercial plastic aprons is not available, make
aprons from plastic sheeting, rubber, or plastic cloth normally used
to cover kitchen tables.


The apron should:


• Have hooks or ties that fasten around the neck.


• Have ties at the waist that reach around and tie at the back.


• Be long enough to cover the top of the boots and provide
additional protection from spills running inside the boots.


Thick gloves: These are worn over an inner pair of thin or latex
gloves. They are worn to clean spills, launder reusable protective
clothing and patient bedding, handle disposable waste, and
conduct autopsies and burial preparations.


Fig. 19. Thick gloves


The gloves can be made of neoprene or thick rubber. They should
reach well above the wrist, about 30 cm (12 inches) up the arm.
When thick rubber gloves are not available, use normal kitchen
gloves as the outer layer of gloves.


If the supply of gloves is limited, wear one pair of gloves.
Disinfect them after each contact with the VHF patient or with
infectious body fluids and contaminated material. How to
disinfect and clean gloves during patient care and for reuse is
described in Sections 5.3 and 5.4.


If gloves are not available, use plastic bags to cover the hands.


Fig. 20. Using plastic bags as gloves


49




Section 4


If nothing is available to serve as a glove or hand covering, make
sure health facility staff wash their hands with soap and water
immediately:


• After every contact with the VHF patient


• Before leaving the patient’s room


• After any contact with infectious body fluids


• After contact with any contaminated material.


How to set up handwashing stations is described in Section 1.3.


Mask: Masks protect the health care worker's face from contact
with blood or droplets of infectious body fluids. Use masks that
cover the mouth and nose. Use a HEPA-filter or other biosafety
mask, a surgical mask, or a cotton mask made locally.


HEPA-filter or biosafety mask: A HEPA-filter mask filters
the air to prevent breathing in small particles and harmful
microorganisms. It provides protection from airborne
transmission of microorganisms.


Fig. 21. HEPA-filter mask


A HEPA-filter or biosafety mask is lightweight and easy to
use. It can be reused by the same health care worker as
long as it continues to fit comfortably and the mask does
not become contaminated, crushed, or splattered with body
fluids.


Do not touch the mask after it has been put on. The mask
may become contaminated once it is touched. To avoid
the necessity for touching the mask, make sure it fits
comfortably before entering the patient’s room.


When handling a reused mask, hold it by the strings. Be
careful that the outside surface does not touch the health
care worker’s face.


50




Wear Protective Clothing


Surgical mask: If HEPA-filter or
other biosafety masks are not
available, use surgical masks.
Surgical masks will not filter out
small particles, but they will
protect the health care worker
from droplets or splashing of
body fluids.


A surgical mask can be reused by the same health care
worker as long as it is not contaminated and not obviously
dirty and torn.


Cotton mask: If surgical masks are not available, use cotton
masks made from four or five layers of cotton cloth sewn
together.


• Use a different colour for
each side of the mask.
This will help health care
workers quickly identify
which side should be
worn inside.


• The mask should have
ties that are long enough
to reach behind the head.


Cotton masks will not provide protection from breathing in
particles, but they will provide protection against splashes
and other droplet contact with infectious body fluids. A
cotton mask can be reused by the same health care worker
as long as it is not contaminated and not obviously dirty
and torn.


Head covering: A head covering or cap protects the hair and head
against splashes from the patient's vomit, blood, or other body
fluids.


Use disposable or cotton
caps. If disposable caps are
not available, make cotton
caps from locally available
cotton fabric. Include ties so
the cap does not fall off when
the health care worker bends
over a patient.


51


Fig. 22. Surgical mask


Fig. 23. Cotton mask


Fig. 24. Head covering




Section 4


If cotton caps are not available:


• Use a scarf, bandanna, or large piece of cloth.


• Fold the scarf, bandanna, or cloth and wrap it around the
head.


Eyewear: Wear clear eyeglasses or non-fogging goggles to protect
the eyes from splashes or spills of infectious body fluids.


Obtain clear eyeglasses from a local
eyeglass shop or in the market.
Place ties on the ear holders. Tie the
eyeglasses around the back of the
head so they will not fall off when a
health care worker bends over a
patient. If available, wear
commercial non-fogging goggles
instead of eyeglasses.


Fig. 25. Wearing clear eyeglasses or
goggles


52




Wear Protective Clothing


4.3 Put On Protective Clothing


Make sure the changing room (and the changing area for cleaning
and other staff) contains a supply of protective clothing. Section
3.4 describes how to set up a changing room.


1. Before entering the changing room, remove jewelry, wallets
and other valuables. Store them safely outside the changing
room.


2. Remove street clothes and
hang them on a hook. Put on
the scrub suit or set of old
clothes.


3. Enter the changing room.


4. Put on rubber boots.


Put on each boot and tuck
the trouser leg inside the
boot. If overboots are used,
tape the top of the boot to
the leg with plastic tape.
This will help prevent spills
from running inside the
boots.


Fig. 26. Scrub suit: the first layer of
clothing


Fig. 27. Putting on boots


53




Section 4


5. Put on the first pair of gloves.


• Look at your hands for cut or broken skin. If the skin
is cut or broken, refrain from direct patient contact.


• Put on one glove at
a time. If the scrub
suit or set of old
clothes has long
sleeves, place the
edge of each glove
under the cuff.


• When only one pair
of gloves is worn,
place the edge of
the glove over the
cuff or gown.


• If gloves are not available, use plastic bags. Put on
one layer now. Attach and close the first layer with
tape or elastic bands.


6. Put on the outer gown.


• Pick up the gown
from the inside.
This is especially
important if the
gown is being
reused.


• Place arms
through the
armholes.


Fig. 28. Putting on the first pair of
gloves


Fig. 29. Putting on the outer gown


• Tie the gown in
back. Or, ask
another health
care worker to tie the gown.


54




Wear Protective Clothing


7. Put on the plastic or rubber
apron.


Fig. 30. Putting on a plastic apron


8. Put on the second pair of gloves.


• Place the edge of the
second pair of gloves
over the cuff of the
gown.


• If using plastic bags,
place the second layer
of plastic bags over the
first. Close ends of the
bags with plastic tape or
elastic bands.


• Health facility staff who
do cleaning, laundering, disinfecting, waste disposal
or handling the body should wear thick gloves as the
second pair of gloves.


9. Put on the mask. Tie it at the back of the neck and towards
the top of the head.


Fig. 31. Proper way to put on the
second pair of gloves


Fig. 32. Putting on mask


55




Section 4


10. Put on a head cover.


Fig. 33. Putting on head cover


11. Put on the protective
eyewear. Attach the
eyeglasses or goggles
behind the head with
string or cord to prevent
the eyewear from falling
off when working with
patients in the isolation
ward.


Fig. 34. Putting on eyewear


Remember! Make sure the mask, head cover and eyewear fit
comfortably. Once gloved hands have touched a patient, do not
touch the mask, headcover and eyewear.


Plan ahead to bring everything into the isolation area for
examining the patient. Once protective clothing has been put on,
do not re-enter the general health facility. In an emergency, ask
the guard or a health assistant to go and obtain any needed items
from other parts of the health facility.


56




Wear Protective Clothing


4.4 Take Off Protective Clothing


The steps for removing protective clothing include disinfection
with bleach solutions and washing hands with soap and water.
How to set up supplies for disinfection is described in Section 3.3.
How to prepare the bleach solutions is described in Section 5.1.


Outer gloves and boots are likely to have the most contact with
infectious body fluids during patient care.


Before leaving the patient’s room:


1. Disinfect the outer pair of gloves.


• Wash the gloved hands in soap and water.


• Dip the gloved hands in 1:100 bleach solution for 1
minute.


2. Disinfect the apron. Spray or wipe it with 1:100 bleach
solution.


3. Disinfect the boots.


Note: The soles of rubber boots are difficult to clean
because they are textured. Disinfect them carefully and
make sure to reach all surfaces of the textured soles.


• Use a sprayer
containing 1:100
bleach solution to
spray boots


OR


• Hold the foot over
a pan or basin and
ask another health
worker to pour
1:100 bleach
solution over the
boots


OR


Fig. 35. Disinfecting the boots


• Step into a shallow pan containing 1:100 bleach
solution and wipe boots on a bleach-drenched cloth.


57




Section 4


4. Remove the outer pair of gloves.


If two pairs of gloves are worn:


• Pull the edge of the glove back over the gloved hand
so that the glove turns inside out as it is being pulled
back.


• If gloves will be reused, place the glove in a bucket
containing soapy water.


Fig. 36.
Disinfecting used
gloves in soapy
water for reuse or
disposing of them
in waste bucket


• If gloves will not be reused, discard them in a bucket
for disposal of contaminated waste.


• Remove the other glove in the same way.


If only one pair of gloves is worn:


• Do not remove the gloves now.


• Rinse the gloved hands in 1:100 bleach solution for
1 minute before leaving the patient’s room.


After disinfecting the boots and removing the outer gloves, go into
the changing room.


58




Wear Protective Clothing


5. Remove the apron and outer gown.


• Put the apron in a
laundry container or
hang it for reuse (if it will
be reused).


Fig. 37. Removing the apron


• Remove the outer
gown. Hang it on a
hook for reuse. Make
sure it is hung inside
out. If the gown needs
laundering, place it in
the laundry container.


Fig. 38. Removing the gown


6. Disinfect the gloved hands
after contact with apron and outer gown.


• Rinse the gloved hands in
1:100 bleach solution.
Then wash them in soap
and water.


• Dry the gloved hands
with a one-use towel.


• If bleach is not available,
wash the gloved hands
with soap and water.


Fig. 39. Washing the gloved hands


59




Section 4


7. Remove the eyewear, head
cover and mask.


• If eyewear is heavily
soiled, wash the
eyeglasses in soapy
water and wipe them
clean. Store them in a
drawer or shelf with
the clean supply of
eyeglasses.


• Remove the head
cover and, if unsoiled,
store it with the
cleaned eyewear. If it
is soiled, place it in the
laundry container or
discard it in the bucket
for disposal of
contaminated waste.


• Remove the mask and
hang it on a hook or
store it for reuse.


• A HEPA-filter or other
biosafety mask can be
reused by the same
health care worker as
long as it is not soiled.


If the HEPA-filter or
other biosafety mask is
soiled, discard it in a
bucket for disposal of
contaminated waste.


Fig. 40. Removing the eyewear


Fig. 41. Removing the head cover


Fig. 42. Removing the mask


• A locally made cotton mask can be reused as long as
it is not obviously dirty and torn.


If it is soiled, place it in the laundry container.


60




Wear Protective Clothing


8. Remove the boots.


• Place a towel that has been soaked in 1:100 bleach
solution on the floor for health facility staff to stand
on when removing boots.


• Use a boot remover to take off the rubber boots.
Avoid touching the boots with bare or gloved hands.


Fig. 43. A boot remover


• Store boots safely until next use. For example, store
them in a plastic sack or on a covered shelf.


9. Remove the inner pair of gloves.


If gloves will be discarded:


• Remove the first glove
with the other gloved
hand. Pull the edge
of the first glove back
over the gloved hand
so that the glove turns
inside out as it is
being pulled back.


• Place the inside-out
glove in the palm of
the gloved hand.


• Reach inside the glove to a clean area. Pull the
glove back over the hand so that only the inside of
the glove is exposed and covers the glove held in
the palm. Discard the gloves in a bucket for
disposal of contaminated waste.


• Wash ungloved hands with soap and water.


61


Fig. 44. Removing the inner gloves




Section 4


If gloves will be reused:


• Reach inside the first glove to a clean area. Pull the
glove back over the hand so the glove turns inside
out as it is pulled back. Place the glove in a bucket
of soapy water.


• Remove the second glove in the same way.


• Place the second glove in soapy water.


• Immediately wash ungloved hands with soap and
water.


10. Remove inner layer of clothes and dress in street clothes.


• If the inner layer is not soiled, store the clothing for
reuse.


• If soiled, place the clothing in the laundry container.


• If personal shower facilities are available, shower
before dressing in street clothes.


• If skin has contact with soiled material, follow
guidelines for accidental exposure in Section 5.13.


• Put on street clothes.


11. Wash hands with soap and clean water before leaving the
changing room.


62




Wear Protective Clothing


Note:


When gloves are in limited supply, use one pair of gloves only.
Modify the order for removing protective clothing as follows:


1. Rinse gloved hands in 1:100 bleach solution
upon leaving the patient isolation room.


2. Remove apron and outer gown as described in
Section 4.4.


3. Remove the gloves.


4. Wash ungloved hands in soap and water.


5. Remove the inner gown or scrub suit, mask,
head cover and eyewear.


6. Wash hands again.


63




Section 4


64




Section 5


Disinfect Reusable Supplies


and Equipment


This section describes how to:


• Prepare disinfectants.


• Clean and disinfect used gloves before reuse.


• Clean and disinfect used medical instruments and supplies.


• Disinfect patient waste and spills of infectious body fluids.


• Disinfect and discard infectious waste and non-reusable
supplies.


• Clean and disinfect protective clothing, boots, and patients’
sheets.


• Give first aid for accidental exposures.




Section 5


66




Section 5 Disinfect Reusable Supplies and Equipment


What to Disinfect: Disinfection kills almost all bacteria, fungi,
viruses, and protozoa. It reduces the number of microorganisms to
make equipment and surfaces safer for use. When VHF is
suspected in the health facility, all medical, nursing, laboratory
and cleaning staff should disinfect:


• Hands and skin after contact with a VHF patient or
infectious body fluids


• Gloved hands after contact with each VHF patient or after
contact with infectious body fluids (when gloves cannot be
changed)


• Thermometers, stethoscopes and other medical instruments
after use with each VHF patient


• Spills of infectious body fluids on the walls and floors


• Patient excreta and containers contaminated by patient
excreta


• Reusable supplies such as protective clothing and patient
bedding


• Used needles and syringes.


Note: All health facility staff — including cleaning, waste disposal,
and laundry staff — who handle, disinfect, or clean
VHF-contaminated supplies and equipment should wear the same
protective clothing as health care workers who provide direct


patient care. Wear thick gloves for the second pair of gloves.
Follow the steps in Section 4 for putting on and taking off
protective clothing.


67




Section 5


5.1 Prepare Bleach Solutions


In a central place in the health facility, prepare two solutions of
ordinary household bleach. Normally, ordinary household bleach
has a 5.0% chlorine concentration.7


• 1:10 bleach solution8 is a strong solution used to disinfect
excreta and bodies. It is also used to prepare the 1:100
bleach solution.


• 1:100 bleach solution9 is used to disinfect:


— Surfaces


— Medical equipment


— Patient bedding


— Reusable protective clothing before it is laundered.


It is also recommended for:


— Rinsing gloves between contact with each patient


— Rinsing gloves, apron, and boots before leaving the
patient’s room


— Disinfecting contaminated waste for disposal.


Bleach solutions must be prepared daily. They lose their strength
after 24 hours. Anytime the odour of chlorine is not present,
discard the solution.


Note: 1:10 bleach solution is caustic. Avoid direct contact with
skin and eyes. Prepare the bleach solutions in a well-ventilated
area.


7 The recommendations in this section assume ordinary bleach solution has a 5% chlorine concentration.
Annex 8 contains a table describing quantities to use when preparing chlorine solutions from other
chlorine products.


8 This is a solution with 0.5% chlorine concentration.


9 This is a solution with 0.05% chlorine concentration.


68




Disinfect Reusable Supplies and Equipment


To prepare the bleach solutions


1. Gather the necessary supplies:


• 1 container that holds 10 measures (for example, 10
litres) to make the base 1:10 bleach solution


• 1 large or several smaller containers (1 for each
station) with covers or lids to hold the 1:100 bleach
solutions. These containers should be a different
colour than the container holding the 1:10 bleach
solution, or they should be clearly labelled “1:100.”


• Chlorine bleach (for example, 1 litre of Javel)


• Clean water


• A measuring cup or other container (for example, a
bottle that holds 1 litre).


2. To prepare the containers for mixing the bleach solutions,
determine where to mark the measurements for “9 parts”
and “1 part” on each container.


• Pour 9 measures of water
into the container. Mark
a line where “9 parts”


Mark inside the has filled the container.
container to show For example, use a nail
where 9 parts of to scratch a line on a
water should be metal or plastic bucket.


• Add 1 measure of water
to the first 9 parts.


9 parts
Mark the level when


Using a nail, mark a bleach is added
line at the point where
the total volume has Fig. 45. Marking container for mixing 1:10
filled the container. bleach solutions


3. To prepare 1:10 bleach solution:


• Fill the marked container with water up to the mark
for 9 parts.


• Then pour the ordinary household bleach into the
container up to the top mark.


69




Section 5


4. To prepare 1:100 bleach solution:


• Measure and pour 9 parts of water into the large
container. Then measure and pour 1 part of 1:10
bleach solution into the water to make 1:100 bleach
solution.


9 parts water
9 parts water


1 part bleach 1 part 1:10 bleach


1:10 1:100


Fig. 46. Preparing bleach solutions


• Distribute a container to each station.


• Fill the container at each station in the isolation area
with the 1:100 bleach solution as shown in Section
3.2.


• Place the remaining 1:10 bleach solution in the
isolation area to disinfect spills and excreta.


• When there is a large outbreak, make larger
quantities of bleach solutions. Prepare the
disinfectants daily and distribute them as described
in Section 3.


• Remove the disinfectants everyday or whenever the
solutions become cloudy or bloody. Replace the
solution with a fresh supply. Safe disposal of bleach
solutions is described in Section 6.1.


70




Disinfect Reusable Supplies and Equipment


• If you cannot smell chlorine in the bleach solution,
the concentration is no longer strong enough for


disinfection. Replace the solution with a fresh
supply.


• Make a schedule for the cleaning staff so they know
when to bring a fresh solution into the isolation area,
when to change them, and when to remove them.


1:100


1:10


Fig. 47. Preparing bleach solutions during an outbreak


71




Section 5


5.2 Prepare Supply of Soapy Water


Prepare a daily supply of soapy water.


1. Gather the necessary supplies:


• Ordinary cake soap or powdered laundry detergent


• Supply of clean water


• Large bucket


• Container for measuring 1 litre.


2. Cut a small piece of cake soap.


2.5cm


2.5cm


2.5cm


Fig. 48. Small piece of cake soap


3. Mix one piece of cake soap with 4 litres (1 gallon) of water.


4. Make sure the soap is well mixed with the water so there
are suds. Pour into pan or bucket for use in cleaning (see
Section 3.3).


OR


5. Mix powdered laundry detergent according to instructions
on packet.


72




Disinfect Reusable Supplies and Equipment


5.3 Disinfect Gloved Hands between Patients


Health care workers should change outer gloves between each
patient.


If there are not enough gloves to allow health care workers to
change to a new pair of outer gloves after examining or treating
each patient, disinfect gloved hands in 1:100 bleach solution after
working with each patient.


To disinfect gloved hands:


1. Place a bucket of 1:100 bleach solution in the isolation
room.


2. If gloved hands are visibly soiled, wash them first in soap
and water.


3. Dip the gloved hands into the 1:100 bleach solution for 1
minute.


4. Dry the gloved hands with a one-use (or paper) towel, or let
the gloved hands air-dry.


5. If a bleach solution is not available, wash gloved hands
with soap and water.


6. After several rinses in bleach solution, the gloves may
become sticky and will need to be changed.


7. If gloves will be reused, place gloves in a bucket of soapy
water. See Section 5.4 for instructions about washing used
gloves.


If gloves are not going to be reused, discard them in the
container for disposable infectious waste.


73




Section 5


5.4 Disinfect Used Gloves before Reuse


Reusing gloves is not recommended. If it is necessary to reuse
gloves because the supply in the health facility is limited, clean
and disinfect them. Also check them for holes.


When cleaning staff handle contaminated supplies, make sure they
wear the same protective clothing as health care workers. They
should wear thick gloves as the second pair of gloves.


To clean and disinfect gloves for reuse:


1. Take the bucket with soaking gloves to the VHF laundry
area. Carefully move the gloves to a bucket with fresh
soapy water.


2. Gently rub the gloves to remove visible soiling and cover
with water.


3. Soak them overnight.


4. Wearing at least an apron
and thick gloves, rinse the
gloves in clean water. To
check for holes, fill each
glove with rinse water. If
any water squirts out, there
is a hole in the glove.
Discard any gloves with
holes.


5. Air-dry the remaining
gloves.


6. If available, put talcum
powder in dry gloves.


7. Return clean gloves to the
storage shelf in the entry to the isolation area.


Fig. 49. Checking gloves for holes


74




Disinfect Reusable Supplies and Equipment


5.5 Disinfect Reusable Medical Instruments


In the isolation room, each time health care workers wash their
hands between patients, they should also disinfect thermometers
and stethoscopes they have used to examine the patient.


To disinfect thermometers and stethoscopes with alcohol:


1. Use rubbing alcohol (70% isopropyl).


2. Place the alcohol in a covered container and put it in the
patient’s room. Change the alcohol at least once a week.


3. Use a clean cloth or paper towel and dip it in the alcohol
solution.


4. Carefully wipe the thermometer with the alcohol solution
and hold the cloth around it for 30 seconds. Discard the
cloth. Let the thermometer air-dry.


5. Use another clean cloth and dip it in the alcohol solution.


6. Carefully wipe the metal part of the stethoscope and hold
the cloth against the surface for 30 seconds. Let it air-dry.


7. Discard the cloth in the laundry container. Discard paper
towels in the bucket for waste to be burned.


To disinfect thermometers and stethoscopes with bleach solution:


1. Place a covered container of 1:100 bleach solution in the
isolation room. Change the bleach solution each day.


2. Use a clean cloth or paper towel and dip it in the bleach
solution. Never dip a soiled cloth back into the bleach
solution. Use a cup or dipper to pour the bleach solution
on a soiled cloth.


3. Wipe the thermometer with the cloth soaked in bleach
solution. Or, soak the thermometer for 10 minutes in the
bleach solution. Let the thermometer air-dry.


4. Use a clean cloth or new paper towel and dip it in the
bleach solution.


5. Wipe the metal part of the stethoscope with 1:100 bleach
solution. Let it air-dry.


75




Section 5


6. Discard the cloth in the laundry container. Discard paper
towels in the bucket for waste to be burned.


How to disinfect and dispose of used needles and syringes is
described in Sections 1.4 through 1.6.


5.6 Disinfect Bedpan or Waste Bucket


1. Cover the contents with 1:10 bleach. Empty the bedpan
contents directly into the isolated toilet or latrine.


2. Clean the bedpan with soap and water to remove solid
waste. Pour into toilet or latrine. Rinse the bedpan in
1:100 bleach solution and return it to patient's room.


If a family member is responsible for carrying out this task, make
sure the family member wears protective clothing.


5.7 Disinfect Patient’s Utensils


If families will assist with patient care, provide 1:100 bleach
solution and soap and water so the family member can wash the
patient’s eating utensils. After washing the utensils, rinse them in
1:100 bleach solution, and let them air-dry.


76




Disinfect Reusable Supplies and Equipment


Fig. 50. Disinfecting a spill on the
floor


5.8 Disinfect Spills of Infectious Body Fluids


Place a bucket containing 1:100 bleach solution in the isolation
area.


To disinfect spills of infectious body fluids:


1. Use a cup or dipper to pour
bleach solution on spills.
Cover the spill completely
with 1:100 bleach
solution. If the spill is heavy
or dense, cover with 1:10
bleach solution. Take care
to prevent drops or splashes
of the contaminated body
fluid from reaching anyone
when pouring bleach
solution on the spill.


2. Soak the spill for at least 15
minutes.


3. Remove the disinfected blood or spilled material with a
cloth soaked with 1:100 bleach solution.


4. Discard any waste in the container for collecting disposable
infectious waste or in the isolated latrine or toilet.


5. Wash area as usual with soap and clean water.


77




Section 5


Fig. 51. Disinfecting a spill on the
wall


To clean the walls or other surfaces:


Surfaces such as tabletops, sinks,
walls and floors are not generally
involved in disease transmission.
However, in a VHF patient’s room,
if walls are visibly soiled with blood
or other body fluids, clean them as
follows:10


1. Use a sprayer or mop to wash
the walls with 1:100 bleach
solution. Rinse the mop in a
fresh supply of 1:100 bleach
solution. (If using a sprayer,
apply the spray close to the surface to minimize splashing
and aerosols.)


2. Wash the wall as usual with soap and clean water to
remove visible soil.


3. Discard any waste in container for collecting infectious
waste or in the isolated latrine or toilet.


5.9 Disinfect Infectious Waste and Non-Reusable
Supplies for Burning


Place a bucket or other container containing 1:100 bleach solution
in the patient’s room. Use it to collect infectious waste,
contaminated items, and non-reusable supplies that will be
burned.


How to carry out safe waste disposal is described in Section 6.


10 Favero, MS, and Bond, WW. Sterilization, disinfection, and antisepsis in the hospital. In: Murray PR ed.
Manual of Clinical Microbiology. Washinton, D.C.: American Society for Microbiology. pp. 183-200,
1991


78




Disinfect Reusable Supplies and Equipment


Fig. 52. Transferring laundry to the
cleaning area


5.10 Clean and Disinfect Protective Clothing


Set aside a special part of the laundry or cleaning area for laundry
from suspected VHF patients. Make sure health facility staff who
handle contaminated laundry wear protective clothing, including
thick gloves as the second pair of gloves.


1. Transfer laundry as soon as
possible to area set aside for
VHF laundry.


2. Carefully move the laundry to
a bucket with fresh 1:100
bleach solution.


3. Soak laundry in 1:100 bleach
solution for 30 minutes. Be
sure that all items are
completely soaked.


4. Remove items from the bleach
solution and place in soapy
water.


5. Soak overnight in soapy water.


6. Scrub thoroughly to remove stains. Rinse and line-dry.


7. Use a needle and thread to repair any holes or torn areas.


8. The clean clothing is now ready for use. It can be ironed
although this is not necessary. (It is not necessary to wear
protective clothing when ironing cleaned clothing.)


Items that are very worn out should be discarded or used as
cleaning rags.


5.11 Clean and Disinfect Boots


Place a sprayer or pan with 1:100 bleach solution at the exit of the
patient's room. Change the pan often. Steps for disinfecting boots
are described in Section 4.4.


79




Section 5


5.12 Clean and Disinfect Patient’s Bedding


For plastic sheeting:


1. If the plastic sheeting becomes soiled during its use with the
same patient, remove liquid or solid waste with absorbent
towels. Discard them in the container for collecting
infectious waste for burning. Then, wash the plastic
sheeting with 1:100 bleach solution.


2. Change the plastic sheeting between patients.


3. If the plastic sheeting cannot be changed between patients,
wash it with 1:100 bleach solution after each patient.


Fig. 53. Cleaning patient’s bedding


For patient’s sheets:


1. Remove sheets from bed. Put them in a container (plastic
bag or bucket) in the patient’s room.


2. Take the container directly to the laundry area.


3. Soak in 1:100 bleach solution for 30 minutes. Be sure all
items are completely soaked.


4. Remove items from the bleach solution and place them in
soapy water. Soak overnight.


5. Scrub thoroughly to remove stains. Rinse and line-dry.


80




Disinfect Reusable Supplies and Equipment


Mattresses:


If a mattress is heavily soiled, remove it from the isolation area to
the outdoors and burn it. Make sure health facility staff wear
protective clothing and gloves when touching and carrying the
soiled mattress.


If mattresses must be reused:


1. Pour 1:10 bleach solution directly on the mattress. Let the
solution soak through completely to the other side.


2. Flood the soiled area with soapy water and rinse with clean
water.


3. Let the mattress dry in the sun for several days.


4. Turn the mattress often so it dries on both sides.


5.13 Give First Aid for Accidental Exposures


Accidental needlestick injury: Assume any needlestick injury is a
suspected contact for VHF whether or not a break in the skin can
be seen. If an accidental needlestick injury occurs, treat the
exposure site.


1. Immerse the exposed site in 70% alcohol for 20 to 30
seconds, and wash with soap and clean water.


2. Flush the site in running water for 20 to 30 seconds.


3. If needed, cover with a dressing.


4. Report the incident to a supervisor or the
physician-in-charge.


The purpose of notifying the physician-in-charge is:


• To identify what caused the problem


• To take corrective action to solve the problem and prevent
accidental transmission


• To provide appropriate care for the possible case of VHF.


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Section 5


Remind the health facility staff that accidents do happen even
when every precaution to prevent them has been taken. Reassure
health facility staff that reporting the accidental exposure will have
no negative consequences. Explain that reporting the accidental
exposure is essential for protecting themselves, their families, other
health workers and patients.


Accidental contact with infectious body fluids: An accidental
contact can occur if there is unprotected contact between
infectious body fluids and broken skin or the mouth, nose or eye.
For example, vomit may run under a glove, a patient might cough
blood which runs into the health care worker's eye, or coughed
blood may run underneath a health care worker's mask and get
into the mouth. Treat any accidental contact as a suspected
contact with VHF. As soon as the contact occurs:


1. Flush the area in the most appropriate manner with soap
and clean water. If a splash occurs in the eye, flush it with
clean water.


2. Leave the isolation area and remove the protective clothing
as recommended.


3. Take a shower and put on street clothes.


4. Report the exposure to a supervisor or the
physician-in-charge. Complete the necessary forms.


Follow up accidental exposures:


1. Monitor the condition of the health facility staff. Take a
measured temperature two times per day.


2. If a fever occurs -- temperature is 38.5oC (101oF) or higher -­
the health facility staff should not do patient care activities.
Treat as a suspected case of VHF if the health facility staff’s
signs and symptoms meet the case definition (Please see
page 23 and Annex 4).


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Section 6


Dispose of Waste Safely


This section describes how to:


• Dispose of liquid waste and patient excreta in an isolated
latrine or toilet.


• Use an incinerator to burn contaminated waste.


• Use a pit to burn contaminated waste.


• Maintain security of the disposal site.




Section 6


84




Section 6 Dispose of Waste Safely


Direct, unprotected contact during disposal of infectious waste can
result in accidental transmission of VHF. For this reason, all
contaminated waste produced in the care of the VHF patient must
be disposed of safely. All non-reusable items should be destroyed
so they cannot be used again. Burning should be carried out at
least daily.


6.1 What Needs Disposal


When VHF is suspected, disinfect and dispose of:


• Infectious blood and other body fluids such as urine, faeces,
and vomitus


• Disposable needles and syringes and disposable or
non-reusable protective clothing


• Treatment materials and dressings


• Non-reusable gloves


• Laboratory supplies and biological samples


• Used disinfectants.


Recommended Disposal Methods: Liquid waste, including patient
excreta, can be disposed of in an isolated latrine or toilet set aside
for VHF cases. Burning is the recommended method for disposal
of other VHF-contaminated waste. A safe and inexpensive
disposal system can be made by using an incinerator or a pit for
burning.


• A latrine or toilet that joins the patient's isolation room can
be used to receive the disinfected bedpan contents from the
VHF patient. The latrine or toilet should be isolated.
Access should be restricted to health facility staff trained to
work in the VHF isolation area. Isolating the patient area is
described in Section 3.5.


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Section 6


• Incinerators are containers with holes for ventilation to
allow air to enter and exit the container. This allows the
fire to reach temperatures high enough to completely
destroy all biological materials. Use flammable fuel (such
as diesel fuel) to speed the burning process and keep the
temperatures high.


Incineration is recommended for disposal of:


— Needles and syringes


— Used treatment materials and dressings


— Non-reusable protective clothing


— Laboratory supplies.


• When an incinerator is not available, burn waste in a pit.
Use fuel to accelerate the burning and ensure that all waste
is completely destroyed.


  Use a pit to dispose of:


— Disinfected body fluids such as urine, faeces, and
vomitus when no designated latrine or toilet is
available.


— Used disinfectants. If it is not possible to dispose of
used disinfectants in a latrine or toilet, burn the used
disinfectant together with flammable items
(disposable gowns or masks, for example). Burning
with the flammable items will help keep the
temperature of the fire hot enough to boil off the
liquids.


Note: All staff who are likely to handle infectious material should
know and use VHF Isolation Precautions. Reinforce with all health
facility staff the importance of handling infectious waste safely.


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Dispose of Waste Safely


6.2 Select Staff to Supervise Waste Disposal and
Burning


Select a person with authority who will:


• Oversee all the disposal procedures, including preparation
of the incinerator and pit.


• Train and supervise the staff who carry out waste disposal.


• Make a schedule for collecting and burning disposable
waste.


• Supervise the collection and burning to make sure it is
carried out safely.


6.3 Train and Supervise Staff to Carry Out Waste
Disposal


The cleaning staff who do the disposal tasks should understand the
purpose of safe disposal, know how to wear protective clothing,
and know clearly how to carry out waste disposal safely.


After the cleaning staff is selected:


1. Describe the risks of VHF transmission. Explain that health
facility staff who carry out waste disposal should wear
protective clothing including a plastic apron and at least
two pairs of gloves. Wear thick gloves as the outer pair of
gloves.


2. Describe the disposal procedures that cleaning staff will
carry out:


• Bring the containers of infectious waste from the
isolation and cleaning areas to the disposal site.
Discard the items in the incinerator or burning pit.


• Pour fuel on the waste in the incinerator or over the
pit. Light the fire.


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Section 6


• Watch the burning carefully.


— Move waste frequently as it burns to be sure
all items burn completely.


— If any items remain, repeat the burning
procedures.


• When burning ends, remove ashes from incinerator
and bury them in a pit.


• When the pit is nearly full of ash, cover it with soil.
Waste should not be near the surface. It should take
about half a meter of soil to close the pit.


• Build a new pit when the old pit is full.


3. Show the cleaning staff how to:


• Wear protective clothing with one pair of thick or
kitchen gloves over an inner pair of thin gloves.


• Collect and carry the buckets of infectious waste
from the isolation area to the disposal area.


• Collect and dispose of liquid waste in an isolated
latrine or toilet. If no latrine or toilet can be isolated,
burn the liquid waste in the pit.


• Place the infectious waste in the incinerator or pit for
burning.


• Dowse the infectious waste with fuel (such as diesel
fuel) and burn it.


• Watch the burning from beginning to end to make
sure all the waste items are burned before letting the
fire go out.


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Dispose of Waste Safely


6.4 Select Site for Burning VHF-Contaminated Waste


Select a burning site on the health facility grounds. It should be
located away from the normal traffic flow. To help maintain
security and prevent unauthorized access, the site should not be in
public view or in an area where it will attract a crowd. The ash
from the burning is not infectious, and it can be placed in a pit and
buried.


6.5 Use Incinerator to Burn VHF-Contaminated
Waste


If an incinerator is available on the health facility’s grounds, and it
can be set aside for VHF-contaminated waste, use diesel fuel
during burning to make sure all the waste is completely destroyed.


If no incinerator is available, make one from an empty 220-litre
(55-gallon) oil or fuel drum.


1. Gather the following supplies:


• 220-litre (55-gallon)
drum


• Chisel or other sharp
instrument (an awl, for
example) to cut metal


• Hammer


• 0.5 mm or 1.0 mm metal
wire


Fig. 54. A 220-litre drum
• The piece cut out from


the top of the drum or a
wire screen or grill about 1 cm thick


• Metal rods or bars 4 cm or 5 cm x 2 cm.


2. Cut open the drum by removing the top in one piece. Save
the top cutaway piece.


3. Hammer the edges of the drum so they are not sharp.


4. Cut three half-moon openings just below the open end of
the drum.


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Section 6


5. Turn the drum and put the
open end on the ground. The
bottom of the drum is now the
top.


6. Cut four holes on the sides of
the drum. These holes are for
threading the two metal rods
through the drum so that they
form an X or cross inside the
drum. The crossed rods will
support a platform used for
holding the infectious material
to be burned.


Fig. 55. Turn the drum and put the
open end on the ground


To cut the holes for the rods:
Just above the half moon
openings (about one-third of the
height of the drum), cut a hole
the same size as the diameter of
the metal rod. Directly across
from the hole, on the other side
of the drum, cut a second hole
so that a rod can be threaded
through the two holes. Repeat
the steps and make two more


Fig. 56. Place the rods across the holes on opposite sides of the drum
drum. Thread each rod through
the holes to make an X or cross.


7. Use the top piece of the drum that was cut away in step 2
to make the platform. It will rest on the crossed rods and
hold the infectious material to be burned. The platform
also lets air come in from the bottom of the drum so that
the temperatures at the bottom are high enough to
completely burn the material.


To make the platform: Punch holes in the cutaway top
piece of the drum. Make enough holes so it looks like a
sieve. Save the platform to use in Step 10.


8. Pierce a series of holes (about 0.5 cm in diameter) on the
sides of the drum and above the crossed rods to improve
the draw of the fire.


half-moon
openings


90




Dispose of Waste Safely


9. Cut away half of the bottom of the drum (which is now the
top of the incinerator and is facing up). Attach the wire
loops to the cutaway half. Attach another loop for a handle
to open the trap door. Items to be burned will be put in the
incinerator through this door.


10. Place the platform you made in Step 7 inside the drum on
top of the rods. Replace the incinerator if, as a result of the
heat, large holes appear in the sides.


metal rods


half-moon
openings


Fig. 57. A completed incinerator


platform


To burn waste in the incinerator:


1. Place the infectious waste inside the top of the drum. Soak
the waste in one litre of fuel.


2. Light the fire carefully.


3. Watch the fire and frequently mix the waste with the metal
bars to be sure all of the waste is burned.


4. When the fire has gone out, empty the ashes into a pit.


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Section 6


6.6 Use Pit to Burn VHF-Contaminated Waste


If an incinerator is not available, make a pit for burning infectious
waste.


1. Locate the pit far from the normal traffic flow of the health
facility.


2. Dig a pit that is 2 meters deep. It should be wide enough
to hold all contaminated waste material, including
discarded liquids.


To burn waste in the pit:


1. Place the disinfected waste in the pit, including disinfected
liquid waste that was not discarded in an isolated latrine or
toilet.


2. Pour fuel (such as diesel fuel) on the waste. Carefully start
the fire.


3. Watch the burning to make sure all the waste is completely
destroyed.


4. When the fire has gone out, if any waste remains, repeat
the steps for burning.


5. When no waste remains and the fire goes out, cover the
ashes with soil.


6. Before the pit becomes completely full, cover it with soil so
that no pieces of waste are visible or are too close to the
surface. The pit should be closed when it can be covered
by one-half meter of soil.


7. Dig a new pit.


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Dispose of Waste Safely


6.7 Take Steps to Ensure Security of Burning Site


Maintain the security of the burning site to limit access to
contaminated items. This is important since children could be
tempted to pick up the interesting waste materials and use them for
toys. Dogs, cats, and other animals may carry items beyond the
health facility boundaries.


Tie a rope around the disposal area. Hang warning signs from the
rope that tell people this is a dangerous area. Also station a guard
to prevent unauthorized access to the disposal area.


Never leave unburned waste in the incinerator or the pit.


93




Section 6


94




Section 7


Use Safe Burial Practices


This section describes how to:


• Prepare bodies of deceased VHF patients.


• Transport the body safely to the burial site.


• Disinfect the vehicle after transporting bodies.




Section 7


96




Section 7 Use Safe Burial Practices


There is risk of transmission in the health facility when a VHF
patient dies because the bodies and body fluids of deceased VHF
patients remain contagious for several days after death. Family
and community members are also at risk if burial practices involve
touching and washing the body.


7.1 Prepare the Body Safely


Burial should take place as soon as possible after the body is
prepared in the health facility. Health facility staff should:


• Prepare the body safely.


• Be aware of the family’s cultural practices and religious
beliefs. Help the family understand why some practices
cannot be done because they place the family or others at
risk for exposure.


• Counsel the family about why special steps need to be
taken to protect the family and community from illness. If
the body is prepared without giving information and
support to the family and the community, they may not
want to bring other family members to the health facility in
the future. They may think that if the patient dies, the body
will not be returned to them.


• Identify a family member who has influence with the rest of
the family and who can make sure family members avoid
dangerous practices such as washing or touching the body.


To prepare the body in the health facility:


1. Wear protective clothing as recommended for staff in the
patient isolation area. Use thick rubber gloves as the
second pair (or outer layer) of gloves.


2. Spray the body and the area around it with 1:10 bleach
solution.


3. Place the body in a “body bag” (mortuary sack) and close it
securely. Spray the body bag with 1:10 bleach solution.


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Section 7


4. If body bags are not available, wrap the body in two
thickness of cotton cloth and soak with 1:10 bleach
solution. Then wrap the body in plastic sheeting. Seal the
wrapping with plastic tape. Spray the body bag as in
Step 3. Place the body in a coffin if one is available.


5. Transport the body to the burial site as soon as possible.
Assign a health officer or health facility staff person to
accompany the body to ensure that the safety precautions
remain secure during the journey.


7.2 Transport the Body Safely


VHF Isolation Precautions should remain in force when the body is
being transported to the burial site.


1. Plan to take the shortest route possible for security purposes
and to limit any possibility of disease transmission through
accidental contact.


2. Any health facility staff who must touch or carry the body
during transport should wear the same protective clothing
as is worn in the isolation area. Note: The driver does not
need to wear protective clothing if there is no contact


with the body.


3. Take a closed container or sprayer with 1:10 bleach
solution in the event of any accidental contact with the
body or infectious body fluids. Also use it to clean up spills
in the transport vehicle.


7.3 Prepare Burial Site


1. The grave should be at least 2 meters deep.


2. Explain to the family that viewing the body is not possible.
Help them to understand the reason for limiting the burial
ceremony to family only.


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Use Safe Burial Practices


7.4 Disinfect the Vehicle after Transporting the Body


1. The staff person who disinfects the vehicle must wear
protective clothing.


2. Rinse the interior of the vehicle where the body was carried
with 1:10 bleach solution.


3. Let it soak for 10 minutes.


4. Rinse well with clean water and let the vehicle air-dry. Be
sure to rinse well because the solution is corrosive to the
vehicle.


Fig. 58. Disinfecting the vehicle after transporting the body


99




Section 7


100




Section 8


Mobilize Community Resources


and Conduct Community


Education


This section describes how to:


• Organize community resources to develop and provide
information about prevention and control of VHF in the
community.


• Identify key messages and communication channels.


• Evaluate communication activities and take action to
improve them as needed.




Section 8


102




Section 8 Mobilize Community Resources and
Conduct Community Education


When VHF is suspected:


• Make sure that the community knows about the VHF
outbreak and how it is transmitted.


• Involve the community in identifying the source of the
epidemic and controlling it.


• Reduce fear and rumours in the population.


To develop community education in an urgent situation:


• Describe the extent of the current health problem.


• Identify and mobilize key community members who will
plan and lead the education efforts.


• Describe the target population and develop health
messages.


• Plan and conduct activities to communicate messages.


• Conduct ongoing evaluation of the activities and make
improvements as needed.


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Section 8


8.1 Identify Key Community Resources


Identify key community organizations who already know the
community and have access to it. Describe their expertise and
available resources that could be useful in responding to the
outbreak. Consider organizations such as:


• Local governments


• Local non-governmental organizations (NGOs)


• Religious groups (missions, churches, mosques, temples)


• Businesses


• Schools


• Sports clubs and other recreational clubs


• Service organizations


• Volunteer organizations and community service groups.


For each organization, gather and record information about:


• The organization's expertise


• The representative or leader to be contacted


• Available human resources


• Available material resources (such as vehicles, office
supplies, and communication equipment).


104




Mobilize Community Resources and Conduct Community Education


Record the information on a chart such as the one below. Use it for planning and refer
to it when VHF cases occur.


Organization
or Group


Expertise Representative
or Leader and


Locating
Information


Human Resources Available
Equipment


Contacted? Tasks
Assigned


Red Cross Emergency
response;
Disaster relief


Amadu Barrie


House next to
hotel


35 trained
volunteers


2 pickup
trucks


Catholic
Mission of St.
Francis


Teaching


Child care


Sister Frances


Use
short-wave
radio at the
Catholic
Mission


6 sisters


4 novices


165 students
residing


1 Land Cruiser


1 storage
room


1 photocopy
machine


1 short-wave
radio


Merchants
Association


Marketing &
community
relations


Kira Talitha


General store
on main road


12 members well
known in
community


41 delivery
workers with
knowledge of
customers'
residence


Wagon


Supplies of
fabric, plastic
cloth, buckets,
household
bleach


Farmers
Cooperative
Organization


Economic
development


Daoudou
Maliki


Government
Centre
Building


Telephone:
21246


2 workers fluent
in language of
rural population


1 short-wave
radio


1 car


office supplies


105




Section 8


8.2 Meet with Community Leaders and Assess the
Current Situation


Invite representatives from each organization to a meeting.


Explain that the goal is to develop a Mobilization Committee that
will help halt an outbreak. Together with the VHF Coordinator
and health facility staff, the Mobilization Committee will:


• Plan and describe how communication will take place
between the Mobilization Committee and the VHF
Coordinator. The purpose is to keep the health staff
informed about the outbreak status in the community.


• Make sure the community leaders understand:


— The signs and symptoms of a VHF.


— How the disease is spread.


— Personal precautions to use to prevent contact with
infectious material and body fluids.


— The person to notify when a VHF is suspected (for
example, station a Red Cross volunteer at the health
facility to take reports from community members
about unexplained deaths or suspected VHF cases).


— The importance of handwashing, decontamination of
surfaces, careful laundering of clothes, bedding, and
other home infection control measures such as trying
to keep the sick person in a separate corner of the
house.


— Careful decontamination of the bedding and room
where the patient has died.


— The need for limited contact between the sick
person and other family and community members.


— The need to follow up family or community
members who have had contact with the sick
person. The duration of the follow up will vary
according to the incubation period for the VHF.


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Mobilize Community Resources and Conduct Community Education


— When to send a sick person to the hospital. The
VHF Coordinator, community liaison person, or Red
Cross volunteer can facilitate this move if the
community has been adequately prepared. For
example, they can assist in transporting the patient
safely to the health facility, help disinfect the area
where the patient was cared for at home.


— How to care for VHF patients at home before they
have been diagnosed and also after they have been
released from the health facility.


— What is expected of families when the patient is in
the hospital.


— Why burial practices may need to be changed
during the outbreak.


• Deliver health messages using a variety of communication
methods that will reach as many people as possible in the
community.


• Conduct community surveillance including reporting
deaths, conducting case finding activities and planning case
follow-up.


Fig. 59. Meeting with community leaders


107




Section 8


8.3 Describe the Target Population


To prepare a complete description of the target population, gather
and present information about:


• Maps of the town


• The size of the population


• Major ethnic groups in the town


• Locations of any special populations such as refugees or
squatter settlements where the risk of disease transmission
may be particularly high


• How many people may be affected by the outbreak


• The populations at greatest risk.


Ask the members of the Mobilization Committee for any additional
information they might have about the target population. For
example, they may know about nearby villages and recent travel
by the local population to other areas.


8.4 Describe Problems Contributing to Transmission
Risk


Identify the likely transmission risks for this community.


For example, does the community know how disease is
transmitted and how it can be prevented? Is it customary to visit
the sick in their homes? During mourning, are individuals
expected to lay hands on the body or touch the body to show their
grief? Are there new skills to teach? Is bleach available?


8.5 Identify Changes or Actions Required


Specify the behaviour changes and actions that are required to
solve the problems. For example, if traditional burial practices
involve touching or washing the body, the community will need to
adapt burial practices.


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Mobilize Community Resources and Conduct Community Education


8.6 Identify Barriers to Carrying Out Recommended
Changes or Actions


Talk with members of the Mobilization Committee about what
could prevent individuals from doing the recommended changes
or actions. Discuss, for example, if individuals:


• Know about the relevant VHF precautions and how to
follow them?


• Have the skills to do the recommended changes or actions?


• Have the correct resources to carry out the recommended
changes or actions?


• Understand that some caretaking and burial practices must
change during the outbreak even though they involve
traditional beliefs or cultural practices?


8.7 Develop Specific Messages


Review the information collected by the Mobilization Committee.
Select messages that match the specific risks for transmission of
VHF. Consider how to solve the obstacles that might prevent
individuals from taking the recommended precautions.


For example, the custom in the community may be to visit the sick
when they are at home. Plan a message about limiting visitors.
Also include information about how diseases are transmitted. This
will help the community understand why they must change their
customary practice.


After selecting the messages, decide if some activities should take
place before others.


For example, give basic information about VHF and its
transmission before telling the community about not touching the
body of a relative who has died.


In addition, the community may have heard rumours that everyone
in the hospital is dying. To reduce fear and rumours, give
information as soon as possible about VHF transmission. Discuss
the precautions being taken in the hospital to protect the patients,
the health facility staff, and the community.


109




Section 8


8.8 Select Activities for Communicating Messages


List all available methods of communicating with the community.
More than one method should be used to reach the maximum
population with the necessary information. For instance, consider:


• Existing communication channels in the community
(church, mosque, temples and other religious networks;
traditional healers, personal communication)


• Door-to-door campaigns


• Radio messages


• Short-wave radio to reach outlying areas


• Banners and posters.


Contact the person responsible for each communication method.
Ask for their support and availability.


8.9 Assign Tasks and Carry Out Activities


Look at the list of community resources prepared in Section 8.1.
Determine who should undertake which activity. For example:


• Religious leaders will make announcements in their
services. They can also prepare messages to deliver to
small groups and in personal communications.


• The Red Cross will be trained to evacuate the bodies and
safely perform burials.


• The Red Cross volunteers and student volunteers will be
trained by a member of the health facility staff skilled in
VHF Isolation Precautions. A training schedule will be set
up and the Mobilization Committee will work out the
information needed.


• The governor or village chief can make public
announcements with a loudspeaker to tell people to stay
calm, to listen to the information, and to attend information
sessions.


• Student clubs will make banners to put across the road to
give a specific message, design leaflets, pass out leaflets,
and go door to door and answer questions.


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Mobilize Community Resources and Conduct Community Education


Elicit ideas from the Mobilization Committee about possible
problems and creative solutions. Describe the problems that have
occurred in previous outbreaks or that might occur in a future
outbreak. Explain that meetings with the group will continue
throughout the outbreak and new problems will be discussed as
they arise.


If funding and human resources are limited, set priorities. Select
specific activities that will make the most impact. Work with the
Mobilization Committee to coordinate and communicate with all
the resources in the community. There may be ways to
accomplish all the activities if groups can be mobilized and
understand the need.


Use the community information sheet to organize the specific tasks
and assign organizations to do them.


8.10 Evaluate Activities


Evaluation of the community education efforts should be ongoing.
Keep records of activities accomplished, any problems, and their
solutions. Use the evaluation results to make improvements.
When problems occur, find out why and solve them. Develop
new solutions to identified problems and implement these
solutions.


For example, in the 1995 Ebola haemorrhagic fever outbreak in
Kikwit, community education was a key element in halting the
epidemic. However, no one predicted that survivors would not be
accepted when they returned into the community. Community
members believed survivors still carried the disease. A new
education activity had to be developed so that the survivors and
surviving children would not be abandoned.


111




Section 8


8.11 Obtain Community Feedback


The Mobilization Committee should identify a representative from
the community or from each area of the community (for example,
a representative from each neighbourhood or quartier) to attend
community meetings and obtain feedback from the community.
Explain to the community the purpose of the Mobilization
Committee. Describe the activities that have been planned or that
are already being done. Reinforce the critical role of the
community representatives in providing information from the
Mobilization Committee to their own communities. Community
representatives are also important sources of information about
possible transmission risks and prevention activities.


Be alert to feedback from the community that can affect the
outcome of the community education efforts. For example, are
there areas where health messages do not reach community
members?


8.12 Meet Regularly with the Mobilization Committee


Set up regular meetings with the Mobilization Committee. Keep
them well informed of what is happening. Encourage and support
them to help continue enthusiasm for the efforts. Provide new
messages and information they need. Work together to identify
new problems and plan solutions.


112




Section 9


Make Advance Preparations to


Use VHF Isolation Precautions


This section describes how to:


• Identify health facility staff person to coordinate VHF
activities.


• Assess current readiness for VHF Isolation Precautions.


• Identify and train key staff who will work with VHF cases.


• Plan for community mobilization.


• Assess current supplies and obtain what is needed for VHF
Isolation Precautions.


• Use substitutions when supplies are limited or not
available.




Section 9


114




Section 9 Make Advance Preparations to Use
VHF Isolationtion Precautions


When a VHF case is suspected, VHF Isolation Precautions must
begin immediately. All efforts must be focused on meeting
patients’ needs. There is no time to give initial training in VHF
Isolation Precautions.


Being prepared for an emergency can ultimately save lives. Health
care workers will know how to use VHF Isolation Precautions, and
adequate supplies will already be available. Disease prevention in
the health facility setting will be more effective.


This section describes how to prepare for VHF Isolation
Precautions.


9.1 Identify a VHF Coordinator to Oversee
Preparations


Someone in the health facility may already serve as a coordinator
for emergency situations. This person can also serve as the VHF
Coordinator. If the emergency coordinator cannot assume the
VHF activities, select a staff person with authority who can serve as
VHF Coordinator. Discuss the tasks the coordinator will need to
do for VHF activities:


• Oversee all the preparations for VHF Isolation Precautions.


• Serve as the focal point for information and leadership
when a VHF case is suspected.


• Inform all health facility staff about VHFs and the risks
associated with them.


• Organize training in VHF Isolation Precautions for medical,
nursing, and laboratory staff who will work directly with
VHF patients or infectious body fluids.


• Assign responsibility to medical, laboratory, and cleaning
staff for ensuring that all the necessary precautions,
treatment protocols and cleanup procedures are carried out
within their areas.


115




Section 9


• Hire or reassign and train additional cleaning staff for work
with disinfection of waste, clothing, and equipment.


• Make sure that teams are trained to prepare and transport
bodies for burial.


9.2 Assess Current Readiness for VHF Isolation
Precautions


Be prepared to use VHF Isolation Precautions by identifying
problems and actions to solve them. Make sure relevant staff
know how to suspect a VHF, especially those who:


• See patients when they arrive at the health facility and
decide where they are next seen


• Work in the outpatient department


• Work in the emergency room.


9.2.1 Monitor Routine Handwashing Practices


Routine handwashing practices should be part of the minimum
level of Standard Precautions used with all patients in the health
facility.


To reinforce consistent handwashing practices, regularly monitor
the practices and improve them as needed. For example:


• Has handwashing been identified as a routine practice in
the health facility?


• Do all staff wash their hands after contact with each patient,
especially new patients with fever?


• Are there reliable supplies of soap and running water or
buckets with clean water available in areas where health
workers should use them?


• Are posters reminding health workers to wash their hands
placed in areas where health workers can see them?


116




Make Advance Preparations to Use VHF Isolation Precautions


9.2.2 Assess Readiness for Identifying Suspected VHF Cases


Assess the need for training your health staff to suspect a VHF. For
example:


• Do health care workers know the case definition for
identifying VHF cases that have occurred in your area?


• Do health care workers know the procedure for informing
the emergency or VHF Coordinator when a VHF is
suspected?


• Do health care workers in the relevant areas know the level
of Standard Precautions identified for the health facility?
Do they use them all the time to prevent health facility
transmission of VHFs and other contagious diseases such as
HIV and hepatitis B?


9.2.3 Assess Readiness for Setting Up a VHF Isolation Area


• Has an area been selected for VHF isolation that meets the
criteria described in Section 3.1?


• Has a map been drawn showing where to locate the
changing room, the patient room, the changing room for
the cleaning staff, and a changing room for family members
(if needed)?


A map that is prepared in advance can be used as a
reference for setting up a VHF isolation area in an urgent
situation.


9.2.4 Assess Readiness of Medical, Laboratory, and Cleaning
Staff


Key staff should be identified and informed about what will be
expected of them when a VHF case is suspected. For example:


• Is there a family liaison officer who will:


— Provide information and help families to care for the
patient


— Help families find a place near the hospital where
cooking, sleeping, and sanitary facilities are
available


— Talk with family members about their concerns?


117




Section 9


• Have the health care workers who will have access to the
isolation area if a VHF case is suspected been identified?
While all health facility staff should know and use Standard
Precautions consistently, identify the health care workers
who must also know how and when to use VHF Isolation
Precautions.


• Have laboratory staff been designated to work with VHF
samples? Laboratory staff are at particular risk of disease
transmission because they handle biological samples. They
do not see the patients and cannot know if the sample is
infected with a dangerous disease. When a VHF case
occurs, limit work on VHF samples to one laboratory staff
person who will do all testing of body fluids from VHF
patients. Make sure the designated person knows when
and how to use protective clothing and safely disinfect
spills and waste.


• Have cleaning staff been selected and trained to use VHF
Isolation Precautions? Cleaning staff have close contact
with infectious spills and equipment. They are at high risk
of transmission if VHF Isolation Precautions are not used.
Select the cleaning staff who will be responsible for
cleaning in VHF isolation areas, laundry areas, and the
body preparation area.


• Have body disposal teams been identified and trained to
use VHF Isolation Precautions? The health facility staff or
Red Cross volunteers who prepare corpses before families
claim them are at risk for VHF. The VHF patient is still
contagious for several days after death.


The VHF Coordinator should also meet with each group to explain
the risk of health facility transmission and the training schedules
and to answer any questions they have.


9.3 Train Health Facility Staff in VHF Isolation
Precautions


Learning to use a new skill takes time and practice. Health facility
staff who do not know how to use VHF Isolation Precautions will
need information about the new tasks, see them demonstrated and
practice doing them. Staff who are not familiar with protective
clothing should practice putting them on and working in them
before a VHF case presents.


118




Make Advance Preparations to Use VHF Isolation Precautions


Include information about VHFs and using VHF Isolation
Precautions during in-service training.11 Discuss topics such as:


General information about VHFs:


• A VHF can be caused by several different viruses, which are
transmitted to humans by animals or arthropods.


• Each virus causes a different disease, but all attack the small
blood vessels that carry blood through the body.


• The virus is usually in all organs and can cause bleeding
from the nose, mouth, and intestine, as well as under the
skin.


• Common presenting complaints are fever, body aches,
weakness persisting after rehydration, diarrhoea, muscle
pain and back pain.


• Clinical examination may reveal only conjunctival injection
(red eyes), mild hypotension (low blood pressure), flushing,
and haemorrhages.


• The course of VHF leads to shock, generalized mucous
membrane bleeding, reduced sensitivity to pain, and signs
involving the nervous system.


• Examples of VHFs include:


Africa: Lassa fever, Rift Valley fever, Marburg and Ebola
haemorrhagic fevers, Crimean-Congo haemorrhagic
fever, and yellow fever.


South America: Argentine haemorrhagic fever, Bolivian
haemorrhagic fever, Venezuelan haemorrhagic
fever, haemorrhagic fever with renal syndrome
(rare), yellow fever, and dengue haemorrhagic fever.


Asia: Haemorrhagic fever with renal syndrome and
dengue haemorrhagic fever.12


11 Annex 14 contains a suggested agenda for training during in-service meetings. It can be adapted by
individual health facilities.


12 See Annex 2 for more information about VHFs reported in your area.


119




Section 9


VHF Transmission Risk in the Health Facility:


Give information about VHF, its transmission, and previous
outbreaks in the area listed in the Introduction and Section 2 of
this manual. Explain that:


• The virus is present in the patient's body fluids.


• It is transmitted through unprotected contact between an
infectious patient or their body fluids and a non-infected
person.


• While VHF is not a common diagnosis, it is a dangerous
disease and poses significant risks in the health care setting.


VHF Isolation Precautions:


When a VHF case is suspected, the health facility will immediately
take steps to limit its transmission. These include steps to:


• Create an isolation room for VHF patients.


• Limit contact with VHF patients to a small number of
specially trained staff and, in some areas, a family member
who has received information and training in VHF Isolation
Precautions.


• Limit the use of invasive procedures as much as possible in
treatment of VHF patients.


• Use protective clothing for all staff who have contact with
VHF patients or their body fluids.


• Use safe disinfection and waste-disposal methods.


Procedures for Accidental Exposures:


Provide information about how to respond when accidental
exposures occur. These procedures are detailed in Section 5.13 of
this manual.


120




Make Advance Preparations to Use VHF Isolation Precautions


9.4 Plan for Community Mobilization


Section 8 describes how to mobilize the community in an urgent
situation. However, community mobilization will be easier and
occur quickly if it is planned in advance.


Now is the best time to establish a Mobilization Committee. The
following steps can be done in advance.


• Identify key community resources.


— Identify key organizations and record them on the
Community Information Sheet (page 105).


— Identify the representative or leader for each
organization.


— Contact the representative or leader for an initial
meeting.


• Meet with identified community leaders.


— Give information and educate them on VHFs.


— Explain the purpose for a Mobilization Committee.


— Discuss and clarify each organization’s expertise.


— Discuss and clarify the human resources available
from each organization.


— Discuss and clarify equipment available from each
organization.


— Establish methods for communicating between the
Mobilization Committee and the VHF Coordinator.


— Record the relevant information on the Community
Information Sheet.


• Annually update the information on the Community
Information Sheet.


Then, when a VHF case is suspected, the committee can meet and
take action to mobilize resources and carry out community
education.


121




Section 9


9.5 Assess Current Supplies and Equipment


Use the checklist at the end of this section to assess which supplies
are already available in the health facility. If these supplies are
available, can they be set aside for use when VHF Isolation
Precautions are needed? If they are not available, could they be
borrowed from another service if an outbreak occurred?


If the supply is limited or unavailable, identify practical, low-cost
substitute items. When an item or equipment is not available,
consider what could be used in its place that will serve the same
function. Obtain the substitute item now. Set it aside for use
when VHF Isolation Precautions are needed.


For example, assess the present system for waste disposal. Find
out what is needed to carry out safe waste disposal when a VHF
case is suspected. Ask health facility staff to prepare an incinerator
(if none is available) so it is ready in advance. Let health facility
staff practice using it before cases occur.


The checklist that starts on the next page lists the necessary items
and recommended quantities. Use it to assess whether an item is
available. Also list what needs to be done to be prepared for VHF
Isolation Precautions.


9.6 Periodically Reassess Supplies


Periodically, for example, every 4 months, make sure the supplies
are dry, clean, and ready to be used.


122




1
2


3


VHF Isolation Precautions Supplies: Standard Precautions
Recommendations for handwashing and safe disposal of sharps*


Recommended Item Recommended Amount Amount
Available


Amount to
Obtain


Local Adaptations Tick if Item is
Ready for Use


Source of clean water prepared as needed


Container for daily supply of water for
handwashing (if running water is not
available)


1 or 2 large containers


Ladle several


Bucket or pan for use with handwashing 1 for each location in the health facility where
handwashing is required


Pieces of soap several bars cut in pieces


Soap dishes 1 for each handwashing station


One-use towels 1 roll per health worker per week


Sharps containers 1 for each location where sharp instruments are used


Pans with soapy water to collect needles
and syringes to be cleaned and
disinfected for reuse


1 for each location where sharp instruments are used


Pans with full-strength bleach 1 for cleaning area


Supply of clean water for rinsing needles
and syringes


1 - 5 litres


Clean and disinfected jar for storing
disinfected needles and syringes


1 for each patient isolation area


* This is a recommended minimum level of Standard Precautions for use with all patients regardless of their infectious status.




1
2


4


VHF Isolation Precautions Supplies: Patient Isolation


Recommended Item Recommended Amount Amount
Available


Amount to
Obtain


Local Adaptations Tick if Item is
Ready for Use


Bed 1 per patient


Mattress or sleeping mat 1 per patient


Plastic sheet to cover mattress 1 per bed


Bedding: bottom sheet and blanket 1 each per patient


Thermometer 1 per patient isolation area (1 per patient if available)


Stethoscope 1 per patient isolation area


Blood pressure cuff 1 per patient isolation area


Covered container for alcohol or bleach
solution used to disinfect thermometer
and stethoscope after use with each
patient


1 per patient isolation area


Sharps container or plastic pan with
bleach solution in it for disposal of used
needles and syringes


1 per patient isolation area


Bedside table or shelf 1 per patient


Large wall clock with a second hand 1 per patient isolation room




VHF Isolation Precautions Supplies: Patient Isolation


Recommended Item Recommended Amount Amount
Available


Amount to
Obtain


Local Adaptations Tick if Item is
Ready for Use


One-use towels 1 roll per patient per week or stay


Bed pan 1 per patient


Screens (or sheets hung from ropes or
lines) placed between VHF patients’ beds


enough length to go around isolation area


Signs saying “Isolation Area: No Access” 10


Poster describing Isolation Precautions 1


1
2


5




1
2


6


VHF Isolation Precautions Supplies: Protective Clothing*


Recommended Item Recommended Amount Amount
Available


Amount to
Obtain


Local Adaptations Tick if Item is
Ready for Use


Scrub suits 1 - 2 reusable scrub suits per health staff


Surgical gowns 3 reusable gowns per health staff


4 disposable gowns per health staff per week


Plastic aprons 1 reusable apron for each health staff who needs one


3 disposable aprons per health staff per week


Thin gloves 3 dozen disposable pairs per health staff per week


Thick or heavy-duty kitchen gloves 2 pairs per health staff


HEPA-filter or other bio-safety mask 1 - 2 per health staff who needs one


Cotton mask 3 - 4 per health staff


Rubber boots 1 pair per health staff


Headcovering 1 - 2 per health staff who needs one


Eyewear 1 pair of goggles or clear spectacles per health staff in
isolation area


Shelf or cabinet with lock 1 outside the changing room




1
2


7


VHF Isolation Precautions Supplies: Protective Clothing*


Recommended Item Recommended Amount Amount
Available


Amount to
Obtain


Local Adaptations Tick if Item is
Ready for Use


Covered shelf for storing disinfected
boots


1 outside the changing room


Hooks, nails or hangers for hanging
reusable gowns and scrub suits


1 for each health staff


Boot remover 1 per changing room


Rolls of plastic tape 1 per changing room


Extra supply of clean protective clothing
(for patient isolation area)


1 - 3 sets (depending on staffing)


Extra supply of clean protective clothing
(for the changing room)


1 - 3 sets


* All health facility staff -- including cleaning, waste disposal, and laundry staff -- who handle, disinfect or clean VHF-contaminated supplies and equipment should wear the same


protective clothing as health care workers who provide direct patient care.




1
2


8


VHF Isolation Precautions Supplies: Disinfection


Recommended Item Recommended Amount Amount
Available


Amount to
Obtain


Local Adaptations Tick if Item is
Ready for Use


Supplies for preparing disinfectants


Plastic bucket with lid or cover for
preparing 1:10 bleach solution


1


Containers for preparing 1:100 bleach
solution


1 large container or several small ones


Measuring cup 1 with measurments marked on it


Bleach 1 litre bleach yields 100 litres of 1:100 bleach
solution


Supplies for disinfection station (changing room and patient room)


Pan or bucket with 1:10 bleach solution 1 per each disinfection station


Pan or bucket with 1:100 bleach solution 1 per each disinfection station


Pan or bucket with 1:100 bleach solution
for collecting reusable gloves


1 per changing room


Bucket or bag for collecting
contaminated, reusable protective
clothing


1 per changing room


Bucket or bag for collecting patient’s
contaminated laundry


1 per patient isolation area


Pan with soapy water for collecting used
needles and syringes


1 per patient isolation area




1
2


9


VHF Isolation Precautions Supplies: Disinfection


Recommended Item Recommended Amount Amount
Available


Amount to
Obtain


Local Adaptations Tick if Item is
Ready for Use


Sprayer, bucket or shallow pan with
1:100 bleach solution for disinfecting
boots


1 for the disinfection station in patient room


Sprayer, 1:100 bleach solution, clean
water for disinfecting spills on floor or
wall


1 per each disinfection station


Mop 1 per each disinfection station


Supplies for laundry


Bucket with 1:10 bleach solution


Buckets with 1:100 bleach solution 2 - 3 (10 - 30 litres of bleach solution is needed daily)


Buckets with soapy water 2 - 3 (10 - 30 litres of soapy water is needed daily)


Source of clean water for rinsing the
laundry


10 - 30 litres/day


Needles and thread for repairing holes in
protective clothing


5 spools and 5 needles


Talcum powder to put in washed gloves 1 tin


Line to air-dry reusable clothes




VHF Isolation Precautions Supplies: Waste Disposal


Recommended Item Recommended Amount Amount
Available


Amount to
Obtain


Local Adaptations Tick if Item is
Ready for Use


Containers with 1:100 bleach solution for
collecting infectious waste


1 per patient isolation area


Pit or incinerator for burning infectious
waste*


1 per facility, pit should be 2 meters deep


Kerosene or petrol 1 litre per week


Wood for burning


Rope to make barrier around the waste
disposal site


enough length to go around the waste disposal site


1
3


0


* If no incinerator is available, make one from an empty 220-litre (55-gallon) oil or fuel drum.




1
3


1


VHF Isolation Precautions Supplies: Safe Burial Practices


Recommended Item Recommended Amount Amount
Available


Amount to
Obtain


Local Adaptations Tick if Item is
Ready for Use


Supply of 1:10 bleach solution prepared as needed


Sprayer 1


Body bags (cotton cloth, plastic sheeting,
plastic tape)


as needed


VHF Infection Control Supplies: Others


Recommended Item Recommended Amount Amount
Available


Amount to
Obtain


Local Adaptations Tick if Item is
Ready for Use


Supply checklist as needed


Patient record forms as needed


Accidental exposure record forms as needed


Training materials for staff training in
VHF Isolation Precautions


as needed




132




ANNEX 1 Standard Precautions for Hospital Infection
Control13


Standard Precautions aim to reduce the risk of disease transmission in the health
care setting, even when the source of infection is not known. Standard
Precautions are designed for use with all patients who present in the health care
setting and apply to:


• Blood and most body fluids whether or not they contain blood


• Broken skin


• Mucous membranes.


To reduce the risk of disease transmission in the health care setting, use the
following Standard Precautions.


1. Wash hands immediately with soap and water before and after examining
patients and after any contact with blood, body fluids and contaminated
items — whether or not gloves were worn. Soaps containing an
antimicrobial agent are recommended.


2. Wear clean, ordinary thin gloves anytime there is contact with blood, body
fluids, mucous membrane, and broken skin. Change gloves between tasks
or procedures on the same patient. Before going to another patient,
remove gloves promptly and wash hands immediately, and then put on
new gloves.


3. Wear a mask, protective eyewear and gown during any patient-care activity
when splashes or sprays of body fluids are likely. Remove the soiled gown
as soon as possible and wash hands.


4. Handle needles and other sharp instruments safely. Do not recap needles.
Make sure contaminated equipment is not reused with another patient until
it has been cleaned, disinfected, and sterilized properly. Dispose of
non-reusable needles, syringes, and other sharp patient-care instruments in
puncture-resistant containers.


5. Routinely clean and disinfect frequently touched surfaces including beds,
bed rails, patient examination tables and bedside tables.


6. Clean and disinfect soiled linens and launder them safely. Avoid direct
contact with items soiled with blood and body fluids.


13 Adapted from Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for Isolation
Precautions In Hospitals, January 1996. Centers for Disease Control and Prevention, Public Health Service, US
Department of Health and Human Services, Atlanta, Georgia.


133




Annex 1


7. Place a patient whose blood or body fluids are likely to contaminate
surfaces or other patients in an isolation room or area.


8. Minimize the use of invasive procedures to avoid the potential for injury
and accidental exposure. Use oral rather than injectable medications
whenever possible.


When a specific diagnosis is made, find out how the disease is transmitted. Use
precautions according to the transmission risk.


• If airborne transmission:


1. Place the patient in an isolation room that is not air-conditioned or
where air is not circulated to the rest of the health facility. Make
sure the room has a door that can be closed.


2. Wear a HEPA or other biosafety mask when working with the
patient and in the patient’s room.


3. Limit movement of the patient from the room to other areas. Place a
surgical mask on the patient who must be moved.


• If droplet transmission:


1. Place the patient in an isolation room.


2. Wear a HEPA or other biosafety mask when working with the
patient.


3. Limit movement of the patient from the room to other areas. If
patient must be moved, place a surgical mask on the patient.


• If contact transmission:


1. Place the patient in an isolation room and limit access.


2. Wear gloves during contact with patient and with infectious body
fluids or contaminated items. Reinforce handwashing throughout
the health facility.


3. Wear two layers of protective clothing.


4. Limit movement of the patient from the isolation room to other
areas.


5. Avoid sharing equipment between patients. Designate equipment
for each patient, if supplies allow. If sharing equipment is
unavoidable, clean and disinfect it before use with the next patient.


134




ANNEX 2 Specific Features of VHFs14


Geographical and epidemiological characteristics of VHFs


Disease Geography Vector/Reservoir Human Infection


• Africa • Tick bites.
Crimean Congo HF Ticks. Tick-mammal-tick


• Balkans • Squashing ticks. maintenance.
• China (Western) • Exposure to aerosols or fomites from slaughtered cattle and sheep (domestic


animals do not show evidence of illness but may become infected when • Former Soviet transported to market or when held in pens for slaughter). Union (Southern)
• Nosocomial epidemics have occurred. • Middle East


Dengue HF, Dengue All Tropic and Aedes aegypti mosquitoes. Increased world-wide distribution of the mosquito and the movement of dengue
Shock Syndrome subtropical Regions Mosquito-human-mosquito viruses in travellers is increasing the areas that are becoming infected.
(DHF/DSS) maintenance. Transmission occurs


with the frequent geographic
transport of viruses by travellers.


• Virus is spread by close contact with an infected person.
Ebola HF and Africa Unknown.


• Route of infection of the first case is unknown. Marburg HF
• Infected non-human primates sometimes provide transmission link to humans.


• Aerosol transmission is suspected in some monkey infections.


• Transmitted by aerosols from rodent to man.
Lassa Fever West Africa Mice. The Mastomys genus of the


• Direct contact with infected rodents or their droppings, urine, or saliva. mouse.
• Person-to-person contact.


Note: The reservoir rodent is very common in Africa and the disease is a major
cause of severe febrile illness in West Africa.


14 Peters CJ, Zaki SR, Rollin PE. Viral Hemorrhagic Fevers, Chapter 10 in Atlas of Infectious Diseases, vol 8, vol ed Robert Fekety, book ed GL Mandell. Philadelphia:
Churchill Livingstone. 1997: pp10.1-10.26.


1
3


5




Geographical and epidemiological characteristics of VHFs


Disease Geography Vector/Reservoir Human Infection


Rift Valley Fever Sub-Saharan Africa Floodwater mosquitoes.
Maintained between mosquitoes
and domestic animals, particularly
sheep and cattle.


• Mosquito bite.


• Contact with blood of infected sheep, cattle, or goats.


• Aerosols generated from infected domestic animal blood.


• No person-to-person transmission observed.


Yellow Fever
• Africa


• South America
Aedes aegypti mosquitoes.


Mosquito-monkey-mosquito
maintenance. Occasional human
infection occurs when unvaccinated
humans enter forest. In an urban
outbreak, virus maintained in
infected Aedes aegypti mosquitoes


and humans.


• Mosquito bite.


• In epidemics, mosquitoes amplify transmission between humans.


• Fully developed cases cease to be viremic. Direct person-to-person
transmission is not believed to be a problem although the virus is highly
infectious (including aerosols) in the laboratory.


1
3


6




1
3


7


Common clinical features of VHFs


Disease Incubation Period Case Fatality Characteristic Features


Crimean Congo HF 3-12 days 15% - 30% Most severe bleeding and ecchymoses (a purplish patch caused by blood
coming from a vessel into the skin) of all the HF.


Ebola HF and
Marburg HF


2-21 days 25% - 90%
• Most fatal of all HF.


• Weight loss.


• Exhaustion and loss of strength.


• A maculopapular (a lesion with a broad base) rash is common


• Post infection events have included hepatitis, uveitis and orchitis.


Lassa Fever 5-16 days Approximately 15%
• Exhaustion and loss of strength.


• Shock.


• Deafness develops during recovery in 20% of cases.


Rift Valley Fever 2-5 days (uncomplicated
disease; incubation for
HF may differ)


50% of severe cases
(about 1.5% of all
infections)


• Shock.


• Bleeding.


• Reduced or no urine production.


• Jaundice.


• Inflammation of the brain.


• Inflammation of the blood vessels in the retina of the eye.


Yellow Fever 3-6 days 20%
• Acute febrile period followed by a brief period of remission.


• Toxic phase follows remission with jaundice and renal failure in severe cases.




Specific clinical findings in different VHFs


Disease haemorrhage Thrombo­
cytopenia1


leukocyte
count 2


rash icterus 3 renal
disease


pulmonary
disease


tremor4 ,
dysarthria5


encephalo­
pathy6


deafness eye lesions


Crimean Congo
HF


+ + + + + + ↓↓ ranging
to ↑


++ + +


Ebola HF and
Marburg HF


+ + + + + data not
available


+ + + + + + + + + Retinitis


Lassa Fever + ranging to
S


+ no change + + + + + ranging
to S


+ +


Rift Valley
Fever


+ + + + + + data not
available


+ + + data not
available


E Retinitis


Yellow Fever + + + + + no change
ranging to ↓↓


+ + + + + + + +


1
3


8


1 abnormally low number of platelets in the circulating + occasional or mild
blood


2 white blood cell count
++ commonly seen and may be severe


+++ characteristic
3 jaundice


S characteristic and seen in severe cases
4 shaking


5 difficulty speaking and pronouncing words due to
↑ occasionally or mildly increased


problems with the muscles used for speaking ↓↓ commonly decreased
6 disease of the brain E May develop true encephalitis




1
3


9


A summary of prevention and treatment of VHFs


Disease Prevention Treatment


Crimean Congo HF
• Tick avoidance.


• Avoid contact with acutely infected animals, especially
slaughtering.


• Use VHF Isolation Precautions when a case is suspected.


• Ribavirin is effective in reducing mortality.


• Ribavirin should be used based on in vitro sensitivity and of
limited South African experience.


Dengue HF, Dengue
Shock Syndrome
(DHF/DSS)


• Mosquito control of Aedes aegypti.


• Vaccines currently under investigation for probable use in
travellers but unlikely to be a solution to hyperendemic dengue
transmission that leads to dengue HF.


• Supportive care. It is effective and greatly reduces mortality.


Ebola HF and
Marburg HF


• Standard Precautions including needle sterilization in African
hospitals are particularly important.


• Use VHF Isolation Precautions when a case is suspected.


• Avoid unprotected contact with suspected patients or infectious
body fluids.


• Avoid contact with monkeys and apes.


• None other than supportive care, which may be of limited utility.


• Antiviral therapies urgently needed.


Lassa Fever
• Rodent control.


• Use VHF Isolation Precautions when a case is suspected.


• Ribavirin is effective in reducing mortality.


• Use Ribavirin in higher risk patients, e.g. if aspartate
aminotransferase (AST) is greater than 150.


Rift Valley Fever
• Vaccination of domestic livestock prevents epidemics in livestock


but not sporadic, endemic infections of humans.


• Human vaccine safe and effective, but in limited supply.


• Veterinarians and virology workers in sub-Saharan Africa are
candidates for vaccine.


• Supportive care.


• Use Ribavirin in haemorrhage fever patients (based on studies in
experimental animals).


Yellow Fever
• Mosquito control of Aedes aegypti would eliminate urban


transmission but forest transmission remains.


• Vaccine is probably the safest and most effective in the world.


• Supportive care.




Annex 2


History of Viral
Haemorrhagic Fevers


Seen in Your Area
Major Signs and Symptoms Transmission Route


140




ANNEX 3 Planning and Setting Up the Isolation
Area


Checklist: Supplies for a Changing Room


Storage Outside the Changing Room:


1. Shelf or cabinet with lock


2. Supply of clean scrub suits, gowns, aprons, gloves, masks,
headcovering, and eyewear


3. Covered shelf for storing disinfected boots


4. Bucket for collecting non-infectious waste


Inside the Changing Room:


1. Hooks, nails, or hangers for hanging reusable gowns, scrub
suits


2. Roll of plastic tape


3. Handwashing supplies: bucket or pan, clean water, soap,
one-use towels


4. Bucket or pan, 1:100 bleach solution for disinfecting
gloved hands


5. Container with soapy water for collecting discarded gloves


6. Container with soapy water for collecting used instruments
to be sterilized*


7. Container with soapy water for collecting reusable gowns,
masks, sheets to launder*


*Place outside the changing room if the changing room is too small


If large amounts of waste on floor:


Sprayer, bucket or shallow pan with 1:100 bleach solution for
disinfecting boots


141




Annex 3


Checklist: Supplies for Patient Area


1. 1 bed with clean mattress or sleeping mat and at least a
bottom sheet and blanket for each bed


2. Plastic sheeting to cover mattress or sleeping mat


3. 1 thermometer, 1 stethoscope, and 1 blood pressure cuff for
each patient or for each patient area


4. 1 puncture-resistant container for collecting non-reusable
needles, syringes, and discarded sharp instruments


5. 1 bedside table or shelf


6. 1 large wall clock with a second hand


7. Pan with 1:100 bleach solution or alcohol and one-use towels
for disinfecting the thermometer and stethoscope between
use with each patient


8. Bucket or pan, 1:100 bleach solution, one-use towels for
disinfecting gloved hands between patients


9. Supplies for disinfecting patient excreta (bedpan, urinal, 1:10
bleach solution)


10. Sprayer, 1:100 bleach solution, clear water, and mop for
disinfecting spills on floor and walls


11. Container with soapy water for collecting discarded gloves


12. Screens (or sheets hung from ropes or lines) placed between
VHF patients’ beds


13. Extra supply of gowns and gloves


14. Container for collecting infectious waste to be burned


142




Planning and Setting Up the Isolation Area


Use the grid on the next page to draw the layout of an isolation area in your own
health facility. Be sure to include:


• Area for patient isolation


• Changing room for health care workers to use for changing clothes


• Area for cleaning and laundering VHF-contaminated supplies


• Changing area for cleaning staff who handle VHF-contaminated waste but
who do not do direct patient-care activities.


143




Annex 3


Planning Grid: Layout for Isolation Area in Your Health Facility


144




ANNEX 4 Adapting VHF Isolation Precautions for a
Large Number of Patients


The recommendations in this manual assume 1 or 2 VHF cases have occurred in a
non-outbreak situation. When more than 1 or 2 VHF patients present in the
health facility, additional precautions need to be taken. When Ebola
haemorrhagic fever occurs, initially there may be as many as 10 cases.


When a VHF is suspected, develop a case definition based on the VHF that has
occurred. Use it to identify new cases during the outbreak. For example, the
current case definition for suspecting Ebola haemorrhagic fever (EHF) is:


Anyone presenting with fever and signs of bleeding such as:


• Bleeding of the gums
• Bleeding from the nose
• Red eyes
• Bleeding into the skin (purple coloured patches in the skin)
• Bloody or dark stools
• Vomiting blood
• Other unexplained signs of bleeding
Whether or not there is a history of contact with a suspected case of EHF.


OR


Anyone living or deceased with:
• Contact with a suspected case of EHF AND
• A history of fever, with or without signs of bleeding.


OR


Anyone living or deceased with a history of fever AND 3 of the following symptoms:
• Headache
• Vomiting
• Loss of appetite
• Diarrhoea
• Weakness or severe fatigue
• Abdominal pain
• Generalized muscle or joint pain
• Difficulty swallowing
• Difficulty breathing
• Hiccups


OR


Any unexplained death in an area with suspected cases of EHF.


145




Annex 4


The current case definition for suspecting Lassa fever is:


Unexplained fever at least 38oC or 100.4oF for one week
or more.


And 1 of the following:


— No response to standard treatment for most
likely cause of fever (malaria, typhoid fever)


— Readmitted within 3 weeks of inpatient care
for an illness with fever


And 1 of the following:


— Edema or bleeding
— Sore throat and retrosternal pain/vomiting
— Spontaneous abortion following fever
— Hearing loss following fever


Prepare Your Health Facility


If there are more than 2 suspected VHF patients, take steps immediately to adapt
the VHF Isolation Precautions for a large number of patients.


1. Reinforce the use of Standard Precautions — especially handwashing —
throughout the health facility. Make sure there is a reliable supply of soap
and clean water in areas where health facility staff have contact with
patients suspected as having a VHF.


2. Make sure adequate supplies of protective clothing are available.


3. Set up a temporary area that is separate from the rest of the facility where
febrile patients can wait to be seen by a health care worker. Also use this
area for patients who have been seen by a health care worker and who are
waiting to go to the isolation area.


Make sure the temporary admission area contains a supply of protective
clothing, buckets with disinfectants in them for collecting disposable waste,
and disinfectants for cleaning and disinfecting spills of infectious materials.


146




Adapting VHF Isolation Precautions for a Large Number of Patients


4. Identify a family liaison person from the health facility staff who can spend
time with families to answer questions, provide information about the VHF
and its transmission. If family members help provide care when relatives
are in hospital, make sure they know how to use protective clothing when
they are with the patient in the isolation area. Help families with
arrangements for cooking, washing and sleeping.


5. Designate a separate building or ward for placing patients with the same
disease together in a single isolation area. Select and isolate a toilet or
latrine for disposal of disinfected patient waste and other liquid waste.


6. Restrict access to the building or ward set aside as the isolation area. Set
up walkways from the temporary area to the isolation area by tying ropes
along the walkway and hanging plastic sheets from them.


7. Prepare a list of health facility staff authorized to enter the isolation area.
Station a guard at the entry to the isolation area, and provide the guard
with the list of authorized persons. The guard will use the list to limit
access to the isolation area to authorized health facility staff and, if
necessary, the caregiving family member.


8. Provide the guard with a sign-in sheet for recording who goes into the
isolation area and the time of entry and departure.


9. Prepare a large quantity of disinfectant solutions each day (bleach solutions
and detergent solutions). Store the disinfectants in large containers. Ask
cleaning staff to change the disinfectants when they become bloody or
cloudy or when the chlorine odour is no longer detectable.


10. Obtain additional patient supplies. Make sure each patient has a bed and
mattress or sleeping mat. Designate medical equipment for use with each
VHF patient (for example, a thermometer, a stethoscope, and a
blood-pressure cuff for each patient). If there are not enough items
available to provide one per patient, be sure to clean and disinfect the
items before use with the next patient.


11. Make sure schedules are carried out as planned for collecting, transporting
and burning infectious waste daily. Make sure that burning is supervised
and that security of the burning site is maintained.


12. Initiate community education activities.


147




Annex 4


148




ANNEX 5 Making Protective Clothing


Instruction on Making Headwear


Materials needed:


Elastic ¾ meter


Cotton cloth 51 cm2 (20 square inches)


A homemade head cover


46 to 50 cm
(18 to 20 inches)


18 cm
(7 inches )


1. Cut a round piece of cotton cloth that is
46 to 50 cm (18 to 20 inches) in diameter.


2. Sew elastic on the edge and shape a circle
18 cm (7 inches) in diameter.


149




64 cm


(25 inches)


20 cm


(7.5 inches)


Placing the tie away


from the edge allows


for overlap so the


back of the gown can


be closed.


Hole for threading


the lower tie.


108 cm


(42 inches)


long


148 to 158 cm


(58 to 62 inches)


Annex 5


Instruction on Making Gown


Materials needed:


1.5 meters cotton cloth to make one gown


150




46 cm (18-inch) loop


or 2 long ties


25 - 30 cm


(10 to 12 inches)


41 cm


(16 inches)


66 to 71 cm


(26 to 28 inches ) wide


100 cm


(40 inches ) long


66 to 71 cm


(26 to 28 inches) wide


Placing the tie away


from the edge allows


for overlap so the


back of the gown can


be closed.


Fold cloth to make


ties or use sewing


tape; about 91 cm


(36 inches) long


Making Protective Clothing


Instruction on Making Aprons


Materials needed (to make 2 aprons):


1¼ meters plastic sheeting or plastic cloth used for covering tables


91 cm (36 inches) sewing tape


151




Annex 5


Instruction on Making a Cotton Mask


1 meter cotton cloth to make at least 2 masks


50 cm in second colour to make the inside of the masks


1. Cut 4 pieces of
cotton cloth to the
size shown.


2. Cut 1 piece from a
different colour.
Use it as the inside
of the mask.


3. Sew the 5 pieces
together and gather
or pleat the vertical
sides to 13 cm (5
inches) long. Sew
all pieces in place.


4. Sew on ties.


28 to 30 cm


(11 to 12 inches)
20 cm


(8 inches)


13 cm


(5 inches)


152




ANNEX 6 Requirements for Purchasing Protective
Clothing


Specifications for Items of Protective Clothing:


This list describes the generic requirements for ordering or purchasing protective
clothing from commercial vendors. Record the amounts needed on this list of
specifications. The list can be photocopied and provided to donors to make sure
that vendor specifications match the recommended specifications. Determine the
quantities needed from the recommendations on the chart in Section 9.


Gowns


Requirements Made from cotton cloth, cotton blend, or disposable fabric. The requirements
are the same for both disposable and reusable gowns.


Gowns should have the following requirements:


— Open at the back with ties at the neck, waist and middle of the back.


— Ribbed or elasticized cuffs.


— Be long enough to reach the knees.


— If only large size is available, larger size can be cut and altered to fit


smaller people.


If elasticized or ribbed cuffs are not available, attach thumb hooks to the end
of the gown's sleeves. The thumb hooks can then be covered with the long
wrist-sleeve of the gloves.


Quantity
needed


Number of disposable gowns _______ Number of reusable gowns _______


Apron


Requirements Aprons are worn if there is risk of direct exposure to body fluids. The aprons


are worn by physicians, nurses, corpse carriers, and cleaners. The


requirements for the apron are the same for disposable or reusable models.


Aprons should have the following requirements:


— Rubber or plastic apron with hooks or ties around the neck and with ties at
the back.


— Made from disposable plastic or heavy plastic which can be disinfected for
reuse.


— Able to fit over gown.


Quantity
needed


Number of disposable aprons _______ Number of reusable aprons _______


153




Annex 6


Caps


Requirements To prevent contamination of hair and head from patient's vomit or blood:


— Use disposable caps.


— If disposable caps are not available, use cotton caps that can be
laundered and reused.


Quantity
needed


Number of disposable caps ______ Number of cotton caps ______


Masks


Requirements Worn to protect mouth and nose from splashes or droplets of patient's body
fluids.


Masks should offer appropriate protection.


1. 3M HEPA or N Series Mask:


— Has preferable exhalation valve


— Lightweight


— Easy to use


2. Biosafety mask that limits 0.3-µm particles


3. Dust-mist masks


4. Surgical masks only protect from droplets splashed in the face. They
are not HEPA rated.


Quantity
needed


HEPA mask _______ Biosafety mask _______ Dust-mist mask _______


Thin gloves


Requirements Thin gloves to permit fine motor function. They can be surgical glove quality
but do not need to be sterile.


— Must reach well above the wrist, preferably 10 to 15 cm (4" to 6") long,


measuring from the wrist up along the arm.


— Should be tested for pinholes.


— May be powdered or non-powdered.


Quantity
needed


Number of pairs _______


154




Requirements for Purchasing Protective Clothing


Thick gloves


Requirements Thick gloves for handling bodies, disinfection, and disposal of infectious
waste.


— Should be made from neoprene or other thick rubber material.


— Must reach well above the wrist, preferably about 30 cm (12”), measuring
from wrist up along the arm.


Quantity
needed


Number of pairs _______


Boots or overboots


Requirements The requirements are the same for both latex overboots which can stretch over
street shoes, and regular rubber boots


— Should be 30 cm (12") high and have textured soles.


— Provide several sizes to meet size requirements of anyone who might use


them (for example, obtain pairs of boots in sizes medium, and large).


Overboots are preferable to regular boots. They take up less space, fewer
sizes are needed, and they are less expensive.


Quantity
needed


Total number of pairs of overboots _______ (medium _____ large _____)


Total number of pairs of rubber boots ______ (medium _____ large _____)


Protective eyewear


Requirements 1. Use non-fogging goggles that are vented at the sides.


2. If non-fogging goggles are not available, purchase clear spectacles locally.


— Should have ties extending from ear holders that can be tied around the
back of the head so glasses will not fall off when health care worker leans
over patient.


Quantity
needed


Number of pairs of non-fogging goggles _______


Number of pairs of clear spectacles _______


155




Annex 6


Other recommended equipment Quantity
needed


Sprayers: backpack style with hose to use for cleaning and disinfecting spills,
rinsing boots, and other decontamination procedures.


Plastic sheets for mattresses and barriers: can be purchased locally.


Waterproof mattresses


Front lamps: to fit over the physician's head to provide light when physician is
examining patients.


Kerosene lamps


Body bags


156




ANNEX 7 Disinfecting Water for Drinking, Cooking and
Cleaning


The Standard Precautions and VHF Isolation Precautions described in this manual
recommend using a source of clean water. In an emergency situation, health
facility staff may not have access to clean running water. For example, if the
power supply is cut off, water cannot be pumped to the health facility. Other
sources of water could be contaminated.


This Annex describes how to use household bleach to disinfect water when clean
running water is not available in the health facility.


Adding a small amount of full strength household bleach to water will disinfect it
enough so that it can be safely used for drinking, cooking, and cleaning.15


1. Locate several containers for storing the disinfected water. They should
have:


• A narrow mouth (to prevent hands being put
into the water)


• A screw top or attached lid


• A spigot, if possible.


Examples include jerry cans, large plastic jugs, or
buckets with spigots and lids that can be firmly
closed.


An example of a water
container


2. Make available:


• At least 1 litre of full strength household bleach. Use the
instructions on the package to prepare a full-strength concentration.


• Pieces of bar soap or powdered soap.


3. Clean and disinfect the containers. To disinfect the containers, wash them
with soap and water, or rinse them with 1:100 bleach solution.


4. Collect water from the available source (for example, a river, stream, or
well used by the village).


15 World Health Organisation: Cholera and other diarrhoeal diseases control -- technical cards on
environmental sanitation. Document WHO/EMC/DIS/97.6. Geneva: 1997.


157




Annex 7


5. Place the water into the disinfected containers, and add 3 drops of full
strength household bleach per litre of water.


Preparing drinking water


6. Mix the water and bleach drops together.


Let the water stand for 30 minutes. This water is now safe to drink and to
use for preparing meals. Clearly label the containers so that the health
facility staff will know that the water is for drinking and is available for use.
Use a marking pen to write DRINKING WATER on the container, or put a sign
on it that says DRINKING WATER.


7. Provide clean water for the:


— Handwashing stations in
areas where health workers
are likely to have contact
with patients who have fever
or with infectious body
fluids.


— Disinfection station where
reusable needles and
syringes are cleaned and
disinfected.


Using stored clean water for handwashing


158




Disinfecting Water for Drinking, Cooking and Cleaning


8. Assign the job of collecting and disinfecting water to a specific health
facility staff person. Give the health staff person information about how to
do the task and why it is important. Make a schedule for collecting and
disinfecting water routinely.


To disinfect a large quantity of water:


1. Determine how many litres the container holds.


Example: 25 litres


2. Calculate the amount of bleach that is needed to disinfect the specified
quantity of water.


Example: Use 3 drops of bleach per litre of clear water.
3 drops x 25 litres = 75 drops.


3. Find a spoon, cup or bleach bottle cap that can be used to measure the
required amount of bleach. Count the number of drops that the measuring
spoon, cup or bottle cap will hold.


Example: 75 drops of bleach = 1 teaspoon


4. Use the measuring spoon or cup to measure the amount of bleach each
time the large quantity of water is disinfected.


159




Annex 7


160




ANNEX 8 Preparing Disinfectant Solutions by Using
Other Chlorine Products


The disinfectants recommended in this manual are made with household bleach.
This table describes how to make 1:10 and 1:100 chlorine solutions from other
chlorine products.


Preparation and Use of Chlorine Disinfectants


Use a chlorine product
to make :


1:10 solution
For disinfecting:


• Excreta


• Cadavers


• Spills


1:100 solution
For disinfecting:


• Gloved hands


• Bare hands and skin


• Floors


• Clothing


• Equipment


• Bedding


Household bleach


5% active chlorine


1 litre bleach per 10 litres
of water


100 ml per 10 litres of
water or


1 litre 1:10 bleach
solution per 9 litres of
water


Calcium hypochlorite
powder or granules 70%
(HTH)


7 grams or ½ tablespoon
per 1 litre of water


7 grams or ½
tablespoon per 10
litres of water


Household bleach


30% active chlorine


16 grams or 1 tablespoon
per 1 litre of water


16 grams or 1
tablespoon per 10
litres of water


161




Annex 8


162




ANNEX 9 Making Supplies: Sharps Container,
Incinerator, and Boot Remover


Making a Sharps Container:


If a puncture-resistant container is not available for collecting used disposable
needles, syringes and other sharp instruments that have penetrated the patient’s
skin, make a container using these instructions.


Materials:


• Plastic bottle or container made from burnable material (empty
plastic water bottles, for example)


• Cardboard box to serve as a stand for holding the plastic bottle


• Plastic tape.


1. Gather several plastic bottles and boxes made from cardboard or other
sturdy, burnable material.


2. Tape the sides and lid of the cardboard box together so the top side is
closed.


3. Draw a circle on the top of the box that is the same diameter as the plastic
bottle.


4. Cut out the circle and leave a hole in
the top of the box.


5. Place the bottle inside the hole. Fill
the bottle 1/3 full with 1:10 bleach
solution.


6. Place the bottle with its stand in the
patient’s room or where disposable
skin-piercing equipment is used.


7. At the end of the day, when disposable
waste is collected, carry the bottle and
its stand to the site for burning
infectious waste. Place the bottle and
box in the pit for burning.


163


An adapted sharps container




Annex 9


Making an incinerator: See Annex 10.


Making a boot remover:


33 cm
(13 inches) 19 cm


(8 inches)


52 cm
(21 inches)


Please bring this picture to the local carpenter.


164




ANNEX 10 Sample Job-Aids and Posters for Use in
the Health Facility


This section includes a series of sample posters that can be photocopied or
hand-copied for use in health facilities. The sample posters and job-aids are
pictorial explanations of how to do the steps described in various sections of this
manual. For example, posters will remind health workers about:


• Using VHF Isolation Precautions


• How to put on and take off protective clothing


• How to build an incinerator.


165




Viral Haemorrhagic Fevers Isolation Precautions


Wash handsas needed


Isolate thepatient


Wearprotectiveclothing


Disposeof needles and syringes safely


Disposeof waste safely


Use safe burial practices




Steps for Putting On Protective Clothing


1 Wear scrub suit
as the first layer
of protective
clothing.


2 Put on rubber
boots.


3 Put on the
first pair of
gloves.


4 Put on the
outer gown.


5 Put on the plastic
apron.


6 Put on the second
pair of gloves.
Place the edge of
gloves over the cuff
of the gown.


7 Put on the
mask.


8 Put on a
head
cover.


9 Put on the
protective
eyewear.




Steps for Taking Off Protective Clothing


1 Disinfect the outer
pair of gloves. 7 Remove the


eyewear.


2 Disinfect the apron
and the boots.


3 Remove the outer
pair of gloves.


4 Remove the apron.


5 Remove the outer
gown.


8 Remove the head
cover.


9 Remove the mask.


10 Remove the
boots.


11 Remove the
inner pair of
gloves.


6 Disinfect the
gloved hands. 12 Wash hands with


soap and clean
water.




Steps for Building an Incinerator


1 Find a 220-litre
(55-gallon)
drum.


2 Cut open the
drum. Remove
and save the top
cutaway piece.


3 Hammer the edges of the drum so they
are not sharp.


4 Cut 3 half-moon
openings just
above the top end
of the drum.


5 Turn the drum
upside down.
The bottom of
the drum now is
the top.


6 Cut 4 holes on
the sides of the
drum. Thread 2
metal rods
through these
holes so that they
cross inside the
drum.


7 Punch holes in the
top cutaway piece
to make a platform.


8 Pierce a series of
holes on the side
of the drum and
above the crossed
rods to improve
the draw of the
fire.


9 Cut away half of
the top. Attach the
wire loops to the
cutaway half to
make a trap door.
Attach another
loop for a handle
to open the trap
door.


10 Place the platform
inside the drum
on top of the
rods.




Annex 10


170




ANNEX 11 Laboratory Testing for VHFs


Always wear protective clothing when handling specimens from suspected VHF
cases. Label all tubes carefully with name, date of collection and hospital
number. Provide a patient summary or fill out a clinical signs and symptoms form
(Annex 12). Contact your district officer for special instructions about collecting
and shipping specimens.


Diagnostic
Test


Samples
required


Preparation &
Storage


Shipping Viruses to be
confirmed


ELISA (Serology) Whole blood* Freeze or Frozen on dry ice Ebola


Detects:


—Viral antigen


Serum or plasma refrigerate


(as cold as
possible)


or ice packs or
both**** Lassa


CCHF


—IgM and IgG Acute and Rift Valley
antibody convalescent** Marburg


Yellow fever


PCR Whole blood or Refrigerate or Frozen on dry ice Ebola


Detects: clot*** freeze or ice packs or both**** Lassa


DNA, RNA CCHF
(genetic material)
from virus


Tissues


(fresh frozen)


Freeze Rift Valley


Marburg
Serum/plasma Yellow fever


Immunohisto- Liver biopsy from Fix in formalin Room Ebola
chemistry fatal cases (can be stored up temperature Lassa
(liver) to 6 weeks) (Do not freeze) CCHF
Detects: Rift Valley
Viral antigen in
cells


Marburg


Yellow fever


Immunohisto- Skin biopsy from Fix in formalin Room Ebola
chemistry fatal cases (can be stored up temperature Lassa
(skin) to 6 weeks) (Do not freeze)


Detects: (any site)


Viral antigen in
cells


Immunohisto- Tissue biopsy Fix in formalin Room Possible
chemistry


(other tissues)


from fatal cases (can be stored up
to 6 weeks)


temperature


(Do not freeze)


detection of
Ebola, Lassa,
CCHF, Rift


Detects: (other tissues, Valley, Marburg,


Viral antigen in
cells


spleen, lung,
heart, kidney)


Yellow Fever


171




Annex 11


* Whole blood can be used for enzyme-linked immunosorbent assay (ELISA)
and may be frozen. Do not centrifuge suspected VHF specimens because
this increases risk to the lab worker. If serum specimens have already been
prepared these can be used. Place specimens in plastic tubes for shipping
and storage and be sure that the tubes are sealed and properly labelled.


** Collect acute-phase specimen when patient is admitted to hospital or
diagnosed as suspected case and collect convalescent-phase specimen at
death or when discharged from the hospital.


*** Whole blood or tissue is preferred, although serum or plasma may provide
results.


**** Use both ice packs and dry ice to provide best results. If dry ice or ice
packs are not available, sample may be shipped at room temperature and
still provide valid results in most cases.


172




ANNEX 12 Skin Biopsy on Fatal Cases for Diagnosis of
Ebola


Ebola virus can be detected in fatal cases from a skin specimen using an
immunohistochemistry test developed by the Centers for Disease Control and
Prevention (CDC) Infectious Diseases Pathology Activity. The skin specimen is
fixed in formalin which kills the virus. The specimen is no longer infectious once
it is placed in formalin and the outside of the vial has been decontaminated. This
vial can be shipped by mail or hand carried to the lab without risk. Results are
available within a week after the specimen arrives at the CDC.


CDC provides Skin Biopsy Kits for the collection of skin samples in formalin. If
these are available in your area, follow the simple instructions that are provided in
the kit. An example of the instructions is on the following pages.


If a kit is not available, the biopsy can still be collected and sent for diagnosis to:


Dr. Sherif Zaki


Centers for Disease Control and Prevention


Infectious Diseases Pathology G-32


1600 Clifton Road, NE


Atlanta, GA 30329-4018


173




Annex 12


174










Check the list of equipment and make sure everything is in place before beginning.


Kit Equipment List: Other items needed:


1. Instruction sheet 1. 1 or 2 buckets for disinfectant
2. Selection criteria and surveillance forms and handwashing
3. (1) box powdered bleach 2. Gowns or plastic aprons
4. (2) pairs latex gloves 3. 10 litres water
5. (1) pair heavy-duty gloves 4. VHF Infection Control Manual
6. (2) masks
7. (1) face shield
8. (1) tweezers and scissors set
9. (1) vial with formalin
10. (1) vial with chaotrope
11. (1) piece hand soap
12. (2) pieces of parafilm
13. (1) mailing tube
14. (1) set mailing labels


Shipping Instructions:


Be sure to fill out the forms with the name of the patient on each page. Number the vial and put
the number on the form. This is very important, especially if you have more than one specimen to
send. Use a pencil to write on the lid of the vial.


The formalin- and chaotrope-fixed specimens are not infectious. The vial can be sent by
normal mail or carried on a plane without risk to the carrier.


Put the forms and the vial containing the specimen into the mailing tube. Close the lid tightly and
seal with tape if available. Put the label on the tube and send it to CDC by the post office. It can
be mailed in your country or if someone carries it to the United States, it can be placed in any
U.S. mailbox.


Please remember to put stamps on the mailing tube.




Surveillance for Viral Hemorrhagic Fever
INSTRUCTION FOR USING THE SKIN BIOPSY KIT


IMPORTANT: The instruments used in the biopsy are for one use only, must not be reused, and
should be disinfected and incinerated after the biopsy. Reusing could result in contamination of
subsequent samples.
See the “Infection Control for Viral Haemorrhagic Fevers” manual for detailed information on how
to properly put on and take off protective clothing and how to make an incinerator.


1. Fill out the patient forms with
the patient’s information.
Include your address for sending
the results. Check the
equipment and make sure you
have everything you need.


8. Place the remaining sample in
the formalin. See example sample
size. Close the cap tightly to
prevent leaks.


2. Prepare the disinfectant
solution. Mix the contents of the
box of bleach in 10 liters of water.


9. Dip the vials in the disinfectant
for 1 minute. Set them aside to dry.


3. Put on the protective clothing. Begin
with the gown, next the latex gloves,
then the kitchen gloves, then the mask,
and finally the face shield or eye
protection. Use a plastic apron if one is
available. See the “Infection Control for
Viral Haemorrhagic Fevers” manual for
detailed information on protective
clothing.


10. Place the rest of the
equipment in the bucket and leave
it for 30 minutes. If you need to
move the cadaver, do so while you
have the protective clothing on.
When you are finished, rinse your
exterior gloves in the disinfectant,
remove them, and drop them in the
bucket.


4. Take the equipment to the work
site. Label vials with patient name
and date. Open the vials of
formalin and chaotrope.* Open the
instruments: the scissors and the
tweezers. Arrange them for use
near the body.


11. Wearing the interior gloves, pour
excess bleach solution out at the base
of the incinerator (without pouring out
equipment). Empty equipment from
bucket by dumping directly into the
incinerator. Remove interior gloves
and place them in the incinerator.
Using caution, light the incinerator.


5. Gently turn the head of
the cadaver to expose the
side of the neck.


12. Wash your hands with soap
and water. The specimen is not
infectious after it is placed in
formalin and chaotrope, and the
outside of the vial is disinfected.


6. With the tweezers and
scissors, cut a piece of skin
approximately 1.5 cm in size
from the neck and remove.


13. Stretch a piece of parafilm
around the closure of each vial to
provide an extra seal. This will
help prevent leakage during transit.
Be sure that both vials are properly
labeled.


7. From the piece of skin, cut a smaller sample
(about the size of a rice grain) and place it in the
chaotrope. See example sample size. Close the
cap tightly to prevent leaks.


14. Place the vials and the
patient forms in the mailing
tube and send to CDC
Atlanta. Do not freeze the
sample.


* Chaotrope is a skin irritant and may be harmful if swallowed or splashed in the eye. Use caution when handling open containers of chaotrope.
In case of contact on skin, wash with soap and water. In case of contact in eyes, flush with water or saline. Get medical attention immediately.
For safety data about formalin, see label on container.




Hemorrhagic Fever Surveillance Form


Vial Number:


Name and location of Health Center:


Name of physician or nurse:


Contact address (Important: to receive results, give a very specific contact address):


Telephone/Fax number:


Patient data
Name:
Age:
Sex: Male Female
Address:


Hospital Number:


Profession or occupation:
Date of first symptoms:
Date of death:


Date of admittance:
Date of biopsy:


If patient was not hospitalized, who cared for the patient?


Are any other family members ill? If yes, relationship:
Symptoms of family member:


If the patient was hospitalized, use the table attached to mark the
symptoms you observed and any other important observations.




Clinical Signs and Symptoms Form


Name of Patient:
Symptoms (Check each one
present)


Date of appearance:


Fever


Diarrhea


Extreme weakness after
rehydration
Nausea


Vomiting


Sore Throat


Headache


Loss of appetite


Muscle pain


Joint pain


Hiccups


Cough


Conjunctivitis


Chest pain


Rapid respiration


Recent loss of hearing


Burning sensations of the skin


Bleeding, specify below: Date of appearance:


Black or bloody vomit


Black or bloody stool


Mouth


Nose


Urine


Skin or puncture site


Other bleeding: (specify)


Other Observations:(specify)




Selection criteria for testing of suspected
viral hemorrhagic fever (VHF)


Patient’s last name, first name:


When to obtain a skin biopsy sample for testing:


The patient had the following symptoms within 2 weeks preceding death:


Fever and


Diarrhea and


One of the following signs:
Headache
Intense weakness after rehydration
Muscle pains
Joint pains
Back pains


Treatment was given with antibiotics and
antimalarials for a minimum of 3 days.


The patient failed to respond to treatment with no definitive diagnosis and died
with at least 3 of the following:


Sore throat or difficulty in swallowing
Red eyes
Skin eruptions
Hiccups
Burning sensation of the skin
Bleeding: nose, mouth, urine, stools (black or bloody), or vomit (black
or bloody)
Rapid respiration
Patient reports another similar death in the family within last 10 days*


* Measures should be taken to put the family and contacts under surveillance.


Obtain a skin biopsy sample , following the instructions given in this document.
The biopsy sample is not infectious once in formalin or chaotrope.


Send it to CDC for testing at the following address:


Special Pathogens Branch, CDC
1600 Clifton Rd., MS G-14
Atlanta, GA 30333, USA


Telephone: (404) 639-1115
TELEX 549571CDCATL




ANNEX 13 Community Education Materials


Examples of posters used to provide information to family members of Ebola
patients. Kikwit, 1995.


Avoid contact with the patient’s
blood, urine, and vomit.


Do not touch or wash the
bodies of deceased patients.


Burn needles and syringes
immediately after use.


Use gloves to handle the
patient’s clothing. Boil soiled


clothing before washing it.


181




Examples of posters or
teaching aids for viral
haemorrhagic fevers


Protect yourself.


Never touch urine, blood, vomit from a patient
with fever.


Wash spills with bleach solution or soap and water.


To prevent transmission of Lassa fever, wear


a gown, gloves and mask.


Wash your hands if you take care of a


patient with fever.




You can get Lassa fever by touching


the blood, urine, or vomitus of


another person with Lassa fever.


In addition to fever, Lassa fever patient may


have: sore throat, back pain, cough,


headache, red eyes, vomiting, or chest pain.


To prevent Lassa fever, keep your


food and water covered.




You can get Lassa fever by touching, playing


with, or cutting up a rat’s dead body.


There is no injection or vaccine to prevent


Lassa fever. To prevent Lassa fever, we must


prevent its spread by rats.




ANNEX 14 Conducting In-Service Training for VHF
Isolation Precautions


In-service training for VHF Isolation Precautions should be ongoing. Provide
training about VHF Isolation Precautions during supervisory visits, staff meetings
or conferences. Also use other channels such as newsletters, bulletins and
job-aids to provide health facility staff with information and reinforce the use of
VHF Isolation Precautions.


Training in skills is most effective if health staff receive information, see examples,
and have an opportunity to practice the skills they are learning. Make sure that
training sessions for each topic include relevant examples and opportunities for
meaningful practice.


Conduct training sessions in small groups with each category of health worker.


• Present information with charts, pictures, posters or information written on
a flipchart or chalkboard. Use drawings from this manual to illustrate the
topic you are presenting.


• Give examples of the skills you would like the health staff to use. For
example, demonstrate the steps for handwashing as you explain aloud
what you are doing.


• Provide the materials and supplies that health staff need to practice the
skill. For example, provide two buckets of clean water, soap and clean,
one-use towels. Ask health workers one at a time to practice washing their
hands. Ask for feedback from the rest of the group about what was done
well and where improvement is needed.


• Provide feedback to the health staff and answer questions. Conclude the
training by summarizing the steps presented in the session. Provide a
job-aid or handout to tape on a wall to remind health facility staff about the
skills they learned in the session.


• Routinely monitor supplies and equipment to make sure that the supplies
for doing the desired skill are available. During supervisory visits, be sure
to acknowledge when you see health staff using the skills well. When
problems occur, find out what has caused them, and take steps to solve
them so that health staff can continue to use the practices consistently.


The following is a sample agenda for in-service training. It describes how to
include topics about VHF Isolation Precautions during monthly staff meetings.
Adapt it to the schedule for your health facility.


185




Annex 14


Month VHF Isolation Precautions Topic


January 1.


2.


3.


4.


Disease Transmission in the Health Care Setting


Identifying Viral Haemorrhagic Fevers: When to Suspect a VHF


General Information about Standard Precautions


Handwashing


February 1.


2.


Recommended Protective Clothing for VHF


Practice Putting On and Taking Off Protective Clothing


March 1.


2.


Preparing Disinfectants


Using Disinfectants


April 1.


2.


Selecting Disposal Sites and Planning Security Barriers


Building an Incinerator


May 1.


2.


Maintaining an Incinerator


Preparing a Pit for Burning Infectious Waste


June 1.


2.


Safe Use and Disposal of Sharp Instruments


Making a Sharps Container


July 1.


2.


Assessing Inventory of Protective Clothing


Identifying Items to Use When Recommended Protective Clothing is not
Available


August 1.


2.


Sites for Isolation Area (Patient Room and Changing Room); Security Barriers


Planning to Set Up an Isolation Area


September 1.


2.


Assessing Available Supplies for Isolation Area


Identifying Items to Use When Recommended Supplies are not Available


October 1. Selecting and Training Caregiving Family Members: VHF, Protective Clothing


November 1.


2.


3.


Using VHF Isolation Precautions during Patient Care


Disinfecting Thermometers, Stethoscopes and Blood Pressure Cuffs


Disinfecting Used Needles and Syringes


December 1.


2.


Procedures for Responding to Accidental Exposures


Standard Precautions -- Especially Handwashing after Examining Patients with
Fever


186




ANNEX 15 Local Resources for Community
Mobilization and Education


Section 8 of this manual describes how to develop community education in an
urgent situation. The first step is to identify key community resources such as
groups who know the community and already have access to it. Information
about each key community resource can be recorded on the following chart. Use
the chart as a reference to identify appropriate community resources that can be
called upon when a VHF occurs.


187




Annex 15


Local Resources for Community Mobilization and Education


Organization
or Group Expertise


Representative or
Leader and


Locating
Information


Human
Resources


Available
Equipment Contacted?


Task
Assigned


188




ANNEX 16 International and Regional Contacts


SWITZERLAND World Health Organization (WHO)


Division of Emerging and other Communicable Diseases Surveillance
and Control (EMC)


Dr David L. Heymann


20 Avenue Appia, CH-1211 Genève 27, Switzerland


Tel: 41-22-791-2660/41-22-791-2661


Fax: 41-22-791-4198


E-mail: HEYMANND@WHO.CH


ZIMBABWE WHO Regional Office for Africa


Dr D. Barakamfitiye


Director, Prevention and Control of Diseases


Medical School, C Ward, Parirenyatwa Hospital, Mazoe Street


P.O.Box BE 773, Belvedere, Harare, Zimbabwe


Tel: 1-407-733-9236


Fax: 1-407-733-9360


E-mail: BARAKAMFITIYED@HTSD.COM at INET


Dr A. Ndikuyeze, Regional Adviser, Prevention and Control of Diseases


Medical School, C Ward, Parirenyatwa Hospital, Mazoe Street


P.O.Box BE 773, Belvedere, Harare, Zimbabwe


Tel: 1-407-733-9240


Fax: 263-479-1214


E-mail: NDIKUYEZEA@SERVER.WHOAFR.ORG


WHO Collaborating Centres for Viral Haemorrhagic Fevers


UNITED STATES OF
AMERICA


Centers for Disease Control and Prevention (CDC)


National Center for Infectious Diseases


Division of Viral and Rickettsial Diseases


Special Pathogens Branch


1600 Clifton Road, MS G-14


Atlanta, Georgia 30329-4018, USA


Telephone: 1-404-639-1115


Fax: 1-404-639-1118


E-Mail: CJP0@CDC.GOV


189




Annex 16


UNITED STATES OF
AMERICA


US Army Medical Research Institute of Infectious Diseases
(USAMRIID)


Fort Detrick, Maryland 21702-5011, USA


Telephone: 1-301-619-4608


Fax: 1-301-619-4625


CENTRAL AFRICAN
REPUBLIC


Institut Pasteur de Bangui


Boite Postale 923


Bangui, Central African Republic


Telephone: 236-614-576


Fax: 236-610-109


FINLAND University of Helsinki


Haartman Institute


Department of Virology


P.O.Box 21


SF-Helsinki, Finland


Telephone: 358-0-434-6490


Fax: 358-0-434-6491


FRANCE Institut Pasteur à Paris


28, rue du Dr Roux


75724 Paris Cedex 15, France


Telephone: 33-1-4061-3088


Fax: 33-1-4061-3151


GERMANY Philipps-University


Institute of Virology


Robert-Koch-Str. 17


D-35037 Marburg, Germany


Telephone: 49-6421-28-6253


Fax: 49-6421-28-8962


KENYA Kenya Medical Research Institute


Mbagathi Road


P.O.Box 54628


Nairobi, Kenya


Telephone: 254-2-722-541


Fax: 254-2-725-950


190




International and Regional Contacts


NIGERIA University of Ibadan


College of Medicine


Department of Virology


Ibadan, Nigeria


SOUTH AFRICA National Institute for Virology


Special Pathogens Unit


Private Bag X4


Sandringham 2131, Zaloska 4


Republic of South Africa


Telephone: 27-11-882-9910


Fax: 27-11-882-0596


SWEDEN Swedish Institute for Infectious Disease Control


S-105 21 Stockholm, Sweden


Telephone: 46-8-735-1300


Fax: 46-8-735-6615


UNITED KINGDOM Centre for Applied Microbiology and Research


Division of Pathology


Porton Down, Salisbury, United Kingdom


Telephone: 44-198-061-2224


Fax: 44-198-061-2731


191




Annex 16


192




193


References


Viral haemorrhagic fevers


Baron RC, McCormick JB, and OA Zubier. Ebola virus disease in southern Sudan:
hospital dissemination and spread. Bull WHO: 61: 997-1003, 1983


Centers for Disease Control and Prevention. Update: Outbreak of Ebola viral
hemorrhagic fever, Zaire, 1995. MMWR: 44: 468-469, 475, 1995


Feldmann H, Klenk HD, and A Sanchez. Molecular biology and evolution of
filoviruses. Archives of Virology: 7suppl: 81-100, 1993


Gear JH. Clinical aspects of African viral hemorrhagic fevers. Reviews of
Infectious Diseases: 11suppl: s777-s782, 1989


Gear JS, Cassel GA, Gear AJ, Trappler B, Clausen L, Myers AM, Kew MC,
Bothwell TH, Sher R, Miller GB, Schneider J, Koornhoh HJ, Gomperts ED,
Isaacson M, and JH Gear. Outbreak of Marburg virus disease in Johannesburg.
British Medical Journal: 4: 489-493, 1975


Johnson KM. African hemorrhagic fevers caused by Marburg and Ebola viruses.
In: Evans AS, ed. Viral Infections of Humans, Epidemiology and Control. New
York: Plenum Medical Book Company. pp. 95-103, 1989


Khan AS, et al. The reemergence of Ebola hemorrhagic fever. Journal of
Infectious Diseases: 1998, in press.


Peters CJ, Sanchez A, Feldmann H, Rollin PE, Nichol S, and TG Ksiazek.
Filoviruses as emerging pathogens. Seminars in Virology: 5: 147-154, 1994


Peters CJ, Johnson ED, Jahrling PB, Ksiazek TG, Rollin PE, White J, Hall W, Trotter
R, and N Jaxx. Filoviruses. In: Morse SS, ed. Emerging Viruses. New York:
Oxford University Press. pp. 159-175, 1991


Peters CJ, Zaki SR, and PE Rollin. Viral hemorrhagic fevers. In: Fekety R, vol. ed.
Mandell GL, book ed. Atlas of Infectious Diseases, vol 8. Philadelphia: Churchill
Livingstone. 10.1-10.26, 1997


World Health Organization. Ebola haemorrhagic fever in Sudan, 1976. Report of
a WHO/International Study Team. Bull WHO: 56: 247-270, 1978


World Health Organization. Ebola haemorrhagic fever in Zaire, 1976. Report of
an International Commission. Bull WHO: 56: 271-293, 1978




Sanchez A, Ksiazek TG, Rollin PE, Peters CJ, Nichol ST, Khan AS, and BWJ Mahy.
Reemergence of Ebola virus in Africa. Emerging Infectious Diseases: 1: 96-97,
1995


Sureau PH. Firsthand clinical observations of hemorrhagic manifestations in Ebola
hemorrhagic fever in Zaire. Reviews of Infectious Diseases: 11suppl: s790-s793,
1989


Patient Management


Centers for Disease Control. Management of patients with suspected viral
hemorrhagic fever. MMWR: 37(suppl 3): 1-16, 1988


Garner JS, Hospital Infection Control Practices Advisory Committee. Guidelines
for Isolation Precautions in Hospitals. Hospital Infections Program, Centers for
Disease Control and Prevention. January 1996


Peters CJ, Johnson ED, and KT McKee Jr. Filoviruses and management of patients
with viral hemorrhagic fevers. In: Belshe RB, ed. Textbook of Human Virology.
St. Louis: Mosby-Year Book. pp. 699-712, 1991


Paverd, Norma. Crimean-Congo haemorrhagic fever: A protocol for control and
containment in a health care facility. Nursing RSA Verpleging: 3(5): 22-29, (6):
41-44, (7): 33-38, 1988


Disinfection


Favero MS and WW Bond. Sterilization, disinfection, and antisepsis in the
hospital. In: Murray PR, ed. Manual of Clinical Microbiology. Washington, D.C.:
American Society of Microbiology. pp. 183-200, 1991


Haverkos HW and TS Jones. HIV, drug-use paraphernalia and bleach. (Review)
Journal of Acquired Immune Deficiency Syndromes: 7: 741-742, 1994


McCoy CB, Rivers JE, McCoy HV, Shapshak P, Weatherby NL, Chitwood DD,
Page JB, Inciard JA, and DC McBride. Compliance to bleach disinfection
protocols among injecting drug users in Miami. Journal of Acquired Immune
Deficiency Syndromes: 7: 773-776, 1994


Ohio State University Extension Service and US Department of Agriculture.
Emergency Disinfection of Water Supplies, AEX-317.
http://www.ag.ohio-state.edu/~ohioline/aex-fact/317.html


194




Watters JK. Historical perspective on the use of bleach in HIV/AIDS prevention.
Journal of Acquired Immune Deficiency Syndromes: 7: 743-746, 1994


Watters JK, Jones TS, Shapeshak P, McCoy CB, Flynn N, Gleghorn A, and
D Vlahov. Household bleach as disinfectant for use by injecting drug users (letter:
comment). Lancet: 342: 742-743, 1993


World Health Organization. Cholera and other diarrhoeal diseases control ­
technical cards on environmental sanitation. Document WHO/EMC/DIS/97.6.
Geneva: 1997


Suggested Readings in French


Baudon D. Virus Ebola et fièvre jaune: les leçons à tirer des épidémies.
Médecine Tropicale: 55: 133-134, 1995


Bausch DG et PE Rollin. La fièvre de Lassa. Annales de l’Institut Pasteur: 8:
223-231, 1997


Feldmann H, Volchkov VE, et HD Klenk. Filovirus Ebola et Marburg. Annales de
l’Institut Pasteur: 8: 207-222, 1997


Ingold FR, Toussirt M, et C Jacob. Les modes de prévention du sida: intérêt et
limites de l’utilisation de l’eau de Javel. Bulletin de l’Académie Nationale de
Médecine: 178: 279-291, 1994


LeGuenno, B. Le point sur l’épidémie de fièvre hémorragique à virus Ebola au
Gabon. Bulletin Épidémiologique Hebdomadaire: 3: 3, 1997


Prehaud, C et M Bouloy. La fièvre de la vallée du Rift - Un modèle d’étude des
fièvre hémorragiques virales. Annales de l’Institut Pasteur: 8: 233-244, 1997


World Health Organization. Fièvre hémorragique à virus Ebola / Ebola
haemorrhagic fever. Weekly Epidemiological Record / Relevé Épidémiologique
Hebdomadaire: 70: 149-151, 1995


World Health Organization. Fièvre hémorragique à virus Ebola: Résumé de la
flambée au Gabon / Ebola haemorrhagic fever: A summary of the outbreak in
Gabon. Weekly Epidemiological Record / Relevé Épidémiologique
Hebdomadaire: 72: 7-8, 1997


World Health Organization. Lutte contre les zoonoses. Fièvre hémorragique de
Crimée-Congo / Zoonoses control. Crimean-Congo haemorrhagic fever. Weekly
Epidemiological Record / Relevé Épidémiologique Hebdomadaire: 71: 381-382,


195


1996




World Health Organization. Une flambée de fièvre de la vallée du Rift en Afrique
orientale, 1997-1998 / An outbreak of Rift Valley fever, eastern Africa, 1997-1998.
Weekly Epideimiological Record / Relevé Epidemiologique Hebdomadaire: 73:
105-109, 1998


Zeller H. La fièvre hémorragique de Crimée Congo. Annales de l’Institut Pasteur:
8: 257-266, 1997


196




Index


Accidental exposure 81-82, 120


Advance preparation for VHF Isolation
Precautions
Assessing readiness 116-118


In-service training 185-186


Preparing for outbreak 146-147


Staff training 118-119


Supplies checklists 41-42, 123-131, 141-142


Burial 45, 48, 49, 97-99


Community mobilization 103-112


Diagnostic testing
Laboratory testing 171-172


Skin biopsy 173, 175-179


Disinfectants
Bleach solutions 34, 41-42, 68-71, 128-129,


141-142, 161


Other chlorine products 161


Soapy water solution 34, 41-42, 72, 141-142


Disinfection
Bedding 80-81


Bedpan 76


Body of deceased patients 97-98


Boots 57, 79


Gloved hands 73


Gloves, reusable 74


Infectious waste 78


Laundry 79


Needles and syringes


Disposable 15-16


Reusable 15


Patient’s utensils 76


Spills 77-78


Thermometers and stethoscopes 75-76


Vehicles, after transporting bodies 99


Water, drinking and cleaning 157-159


What to disinfect 67


Family
Role in patient care 39-40


Burial 97


Glossary 8


Isolation area 117
Plan 32, 143-144


Purpose 31


Requirements 31-32


Security 37-38


Supplies 34-36


Isolation area (changing room)
Checklist of supplies 41, 141


Sample layout 32, 33


How to set up 37


Isolation area (patient area)
Checklist of supplies 42, 142


Sample layout 32, 33


Posters 26, 165-169, 181-184


Protective clothing
Making protective clothing 149-152


Order for putting on clothing 53-56


Order for taking off clothing 57-62


Purchasing protective clothing 153-155


Recommended items 45-46


Apron 48-49


Boots 47


Eyewear 52


Gloves 46, 49-50


Gown 47-48


Head cover 51-52


Mask 50-51


Scrub suit 46


Who needs to wear protective clothing 45


Standard Precautions 11
Handwashing 12-13, 116, 133


Minimum level for your health facility 12


Disposal of sharp instruments 14-16, 133


Precautions 133-134


Viral haemorrhagic fevers
Case definitions 145, 146


Clinical features 137, 138


Epidemiology 135-136


General 3, 119


Prevention 139


Reporting 27


Suspecting 21-23


Transmission 3, 4, 120


VHF Coordinator
Role 18, 115-116


Selection 18, 115-116


197




VHF Isolation Precautions
Adapting for a large number of patients


145-147


Recommended precautions 17, 120


Reducing risk of transmission 17, 25-26


When to begin using 22, 23, 25, 26


Who needs to use 16, 25, 117-118


Waste disposal
Incinerator 86


Items to be disposed of 85


Methods 85-86


Pit 92


Making an incinerator 89-91


Selecting and training staff 87-88


Selecting site 89


Security 93


198




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