Management of patients in Germany with suspected viral haemorrhagic fever and other potentially lethal contagious infections

[West Africa Ebola outbreak - immediate and hands-on formation: the pre-deployment training program for frontline aid workers of the German Red Cross, other aid organizations, and the German Armed Forces, Wuerzburg, Germany 2014/15]

BACKGROUND

In September 2014, the German government mandated the German Red Cross (GRC) and the German Armed Forces to support the international efforts to stop the epidemic of Ebola virus disease (EVD) in West-Africa. The GRC requested specific training from the Medical Mission Institute Wuerzburg (MI).

OBJECTIVES

We describe and discuss the development, strategy, results, and evaluation of the program to formulate conclusions and recommendations for similar emergencies.

METHODS

On 26 September 2014, it was agreed to establish a two-day training program to prepare Ebola aid workers for the treatment of EVD patients and infection protection in Ebola treatment centers (ETC) in the epidemic area. Course evaluation was based on protocoled discussions with participants and standardized questionnaires.

RESULTS

The training started on 6 October 2014. By 24 February 2015, 214 trainees participated in 14 courses. Of 96 GRC staff deployed to West Africa, 90 (94%) participated in the training. Course content included containment strategy in filovirus outbreaks and practical exercises for standardized procedures in personal protective equipment (PPE). The average trainer-trainee ratio in PPE exercises was 1:3. "Excellent" or "good" ratings were received on 93% of the evaluations.

CONCLUSION

Rapid implementation was possible by teaching a harmonized, and field-approved concept for infection protection and treatment. Realistic simulated scenarios and field-experienced trainers allowed transfer of knowledge as well as reassurance. Additional recommendations are further conversion of the training into a permanent program and, in the case of a crisis, interlocking of training with operational planning to allow rapid escalation and adaptation. Also, the concepts for training and interventions should be harmonized and developed further for additional challenges like airborne transmission and application of intensive-care medicine.

Viral Haemorrhagic Fever (VHF) and Other Serious Viral Infections

Viral haemorrhagic fever—VHF—virus and a number of other special viruses are considered to cause the world’s most dangerous infections with very high mortality, lack of therapeutic possibilities and often absence of effective vaccines. Such viruses are identified as “biohazard-level 4” agents and are treated at the highest level of infection protection with strict isolation measures. At least 14 patients with Ebola disease were transported to Europe and the United States (11 patients) for hospital treatment during the African epidemic in 2014. There were no secondary spread of VHF import cases in Europe and the United States from 1999 until the Ebola outbreak in 2014. Then there were three cases of nosocomial spread to personnel in hospitals, two in the United States and one in Spain, despite alleged use of strict containment routines. This indicates a high risk of spread of infection through intensive treatment and handling of very sick persons with VHF like Ebola. In most cases vaccines are not available or specific antiviral drugs. Therefore, infection control must be based on a proper infection protection. This chapter is focused on practical means to handle and treat patients with suspect VHF or other dangerous agents to avoid spread to personnel and environment

Control measures following a case of imported Lassa fever from Togo, North Rhine Westphalia, Germany, 2016

In a patient transferred from Togo to Cologne, Germany, Lassa fever was diagnosed 12 days post mortem. Sixty-two contacts in Cologne were categorised according to the level of exposure, and gradual infection control measures were applied. No clinical signs of Lassa virus infection or Lassa specific antibodies were observed in the 62 contacts. Thirty-three individuals had direct contact to blood, other body fluids or tissue of the patients. Notably, with standard precautions, no transmission occurred between the index patient and healthcare workers. However, one secondary infection occurred in an undertaker exposed to the corpse in Rhineland-Palatinate, who was treated on the isolation unit at the University Hospital of Frankfurt. After German authorities raised an alert regarding the imported Lassa fever case, an American healthcare worker who had cared for the index patient in Togo, and who presented with diarrhoea, vomiting and fever, was placed in isolation and medevacked to the United States. The event and the transmission of Lassa virus infection outside of Africa underlines the need for early diagnosis and use of adequate personal protection equipment (PPE), when highly contagious infections cannot be excluded. It also demonstrates that larger outbreaks can be prevented by infection control measures, including standard PPE.

[Structural requirements for the management of patients with highly contagious life-threatening infectious diseases: update 2015]

The care of highly contagious life-threatening infectious diseases (HLID) requires specialized treatment facilities that are capable of strict isolation measures and appropriate medical treatment. The German approach to the management of these diseases, which is maintained by the Permanent Working Group of Medical Competence and Treatment Centers for Highly Contagious and Life-Threatening Diseases (STAKOB) is adjusted in the present publication with regards to recent experiences and upcoming needs. Clear synergies in using infrastructures and bundling of resources have led to similar efforts at the European level. The German concept, therefore, has a pioneering role. This update is intended to improve professional patient care and also minimize the risk of disease spread and transmission.

The impact of Crimean-Congo hemorrhagic fever virus on public health

Climatic, environmental and economic changes, as well as the steadily increasing global trade and personal mobility provide ample opportunities for emerging pathogens with zoonotic potential to spread to previously unaffected countries. Crimean-Congo hemorrhagic fever virus (CCHFV) is considered to be one of the major emerging disease threats spreading to and within the European Union following an expanding distribution of its main vector, ticks of the genus Hyalomma. Every year more than 1000 human CCHF cases are reported from countries of southeastern Europe and Turkey. CCHFV can cause high case fatality rates and can be transmitted from human to human. There are no vaccine prophylaxis and therapeutic interventions available at present. Several EU-funded research projects focus currently on CCHFV which highlights the awareness for this problem at the European level. As public health deals with questions of prevention on a population level rather than healing and health on an individual level, the analysis of existing data plays a fundamental role to minimize its epidemic potential, by reducing infection risks, and to manage disease outbreaks. This review gives a summary of the current knowledge and data with focus at the interface between public health and CCHFV. Based on this knowledge, guidelines for the risk classification of a region and for outbreak prevention are given. This review will assist decision makers and public health authorities in understanding risk scenarios and in deciding on effective countermeasures, as well as human and veterinary scientists by highlighting existing gaps in knowledge.

Response to imported case of Marburg hemorrhagic fever, the Netherland

Adventure tourism may bring this disease to Western countries.

On July 10, 2008, Marburg hemorrhagic fever was confirmed in a Dutch patient who had vacationed recently in Uganda. Exposure most likely occurred in the Python Cave (Maramagambo Forest), which harbors bat species that elsewhere in Africa have been found positive for Marburg virus. A multidisciplinary response team was convened to perform a structured risk assessment, perform risk classification of contacts, issue guidelines for follow-up, provide information, and monitor the crisis response. In total, 130 contacts were identified (66 classified as high risk and 64 as low risk) and monitored for 21 days after their last possible exposure. The case raised questions specific to international travel, postexposure prophylaxis for Marburg virus, and laboratory testing of contacts with fever. We present lessons learned and results of the follow-up serosurvey of contacts and focus on factors that prevented overreaction during an event with a high public health impact.

Framework for the design and operation of high-level isolation units: consensus of the European Network of Infectious Diseases

Patients with highly infectious diseases require safe, secure, high-quality medical care with high-level infection control, which may be most effectively delivered by specially trained staff in the setting of a high-level isolation unit (HLIU). The European Network of Infectious Diseases is a European Commission co-funded network of experts in the management of highly infectious diseases from national (or regional) centres designated for the care of this patient population. Participants took a consensus-based approach to develop a framework for the design and operation of HLIUs in Europe, covering clinical care provision, diagnostic services, transport, health and safety, and essential design and construction features, to support planning by health authorities for the safe and effective management of highly infectious diseases and preparedness for infectious disease emergencies in Europe.

Lassa virus

Lassa virus is a RNA virus belonging to the family of Arenaviridae. It was discovered as the causative agent of a hemorrhagic fever--Lassa fever--about 30 years ago. Lassa fever is endemic in West Africa and is estimated to affect some 100,000 people annually. Great progress in the understanding of the life cycle of arenaviruses, including Lassa virus, has been made in recent years. New insights have been gained in the pathogenesis and molecular epidemiology of Lassa fever, and state-of the-art technologies for diagnosing this life-threatening disease have been developed. The intention of this review is to summarize in particular the recent literature on Lassa virus and Lassa fever. Several aspects ranging from basic research up to clinical practice and laboratory diagnosis are discussed and linked together.