Implementation of the Canadian Contingency Plan for a Case of Suspected Viral HemorrhagicFever • Author(s): Mark Loeb , MD, MSc; Douglas MacPherson , MD; Michele Barton , MD; Jan Olde ,RN, CICSource: Infection Control and Hospital Epidemiology, Vol. 24, No. 4 (April 2003), pp. 280-283Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/502202 .

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280 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY April 2003

IMPLEMENTATION OF THE CANADIAN CONTINGENCY

PLAN FOR A CASE OF SUSPECTED VIRAL

HEMORRHAGIC FEVER

Mark Loeb, MD, MSc; Douglas MacPherson, MD; Michele Barton, MD; Jan Olde, RN, CIC

Viral hemorrhagic fevers (VHFs) are illnesses asso-ciated with geographically restricted viruses that cause dis-eases such as Lassa fever, Congo–Crimean hemorrhagicfever, Marburg virus hemorrhagic fever, Ebola hemor-rhagic fever, and Bolivian and Venezuelan hemorrhagicfever.1,2 These diseases generally begin with a nonspecificpresentation that evolves to include hemorrhage (whichmay be subtle), and potentially shock and subsequentdeath, and are transmitted by exposure to infected patientblood and body secretions and excretions.1,3 Given theever-increasing speed and volume of air travel in today’sworld, the risk that individuals incubating VHF may arrivein nonendemic regions, such as North America, isincreased.4 Hospital epidemiologists and infection controlpractitioners therefore may be faced with travelers who,based on travel exposures and clinical features, have a clin-ical presentation that may be compatible with VHF.Although the vast majority of such travelers will have otherconditions, infection control staff are required to be pre-pared for such a suspected acute case.

In anticipation of such an occurrence, the Center forDisease Control published guidelines in 1988; these guide-

lines were updated in 1995.5,6 Similarly, federal Canadiancontingency plans were updated in 1997 by Health Canadaand in 2002 by the Province of Ontario.7,8 These contin-gency plans are comprehensive, dealing with issues rang-ing from the use of barrier precautions to recommenda-tions for eventual disposal of the body if death occurs.However, the experience with implementing these contin-gency plans in Canada is limited because there have beenno recognized imported cases of symptomatic acute VHFof infection control concern. Consequently, these contin-gency plans have not received “real world” evaluation.

In February 2001, the presentation of a patient with aclinical picture compatible with VHF led to the implementa-tion of the Canadian contingency plan for suspected VHF. Thisarticle describes infection control management issues fromthe perspective of the admitting hospital. Recommendationsof the Canadian contingency plan are summarized and thecorresponding implementation is described.

CASE PRESENTATION

On February 4, 2001, a 32-year-old Congolesewoman presented at 7:30 pm to the emergency department

Dr. Loeb is from the Hamilton Regional Laboratory Program and the Departments of Pathology and Molecular Medicine and ClinicalEpidemiology and Biostatistics, McMaster University, Hamilton; Dr. MacPherson is from the Office for Public Health Security, Centre for EmergencyPreparedness and Response, Health Canada, Ottawa, and the Faculty of Health Sciences, McMaster University, Hamilton; and Dr. Barton and Ms. Oldeare from Hamilton Health Sciences, Hamilton, Ontario, Canada.

Address reprint requests to Mark Loeb, MD, MSc, Henderson General Hospital, Hamilton, Ontario, Canada L8V 1C3.The views expressed in this article are solely those of the authors and do not represent the position or views of Health Canada.The authors thank Dr. Monir Taha, Acting Medical Officer of Health, City of Hamilton Social and Public Health Services Department, for review-

ing the manuscript.

OBJECTIVE: To describe the implementation of theCanadian contingency plan for viral hemorrhagic fever (VHF) inresponse to a suspected case.

SETTING: A 300-bed, tertiary-care, university-affiliatedhospital.

PARTICIPANTS: A 32-year-old Congolese woman admit-ted to the hospital with suspected VHF in February 2001. Contactevaluation included hospital healthcare workers and laboratorystaff.

INTERVENTION: Enhanced isolation precautions wereimplemented in the patient care setting to prevent nosocomialtransmission. Contact tracing and evaluation of close and high-riskcontacts with symptoms was conducted. Laboratory precautionsincluded barrier precautions and diversion of specimens.

Communication occurred to both hospital employees and themedia.

RESULTS: Three high-risk contacts, 13 close contacts, and60 casual contacts were identified. Two close contacts becamesymptomatic and required evaluation. Challenging process issuesincluded tracing of laboratory specimens, decontamination of lab-oratory equipment, and internal and external communication.After 5 days, a transmissible VHF of public health consequencewas ruled out in the index case.

CONCLUSION: Contingency plans for VHF can be imple-mented in an efficient and feasible manner. Contact tracing, labo-ratory issues, internal communication, and media interest can beanticipated to be the key challenges (Infect Control Hosp Epidemiol2003;24:280-283).

ABSTRACT

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Vol. 24 No. 4 IMPLEMENTATION OF CONTINGENCY PLAN FOR SUSPECTED VHF 281

of a 300-bed, tertiary-care, university hospital with a 48-hour history of headache, fever, and vomiting. She hadarrived in Canada 24 hours earlier from the DemocraticRepublic of Congo. On presentation, details of her recentexposures, travel history (including the routing toCanada), medical history, and condition on the trip werevague. She had a temperature of 38.5°C and exhibited con-fusion. There was bleeding from her nose, mouth, and uri-nary tract. There were no conjunctival, meningeal, or focalneurologic abnormalities. Tenderness was noted in herright upper quadrant, but her liver was not enlarged andher spleen could not be palpated.

Preliminary laboratory studies disclosed the followingvalues: hemoglobin, 82 g/L; white blood cell count, 8.9 �109/L; platelet count, 55 � 109/L; bilirubin, 101 µmol/L (con-jugated, 38 µmol/L); aspartate aminotransferase, 93 µ/L; andalanine aminotransferase, 26 µ/L. Her international normal-ized ratio was 1.2 (normal, 1.0 to 1.3), and partial thrombo-plastin time was 30 seconds (range, 26 to 38). ThreePlasmodium falciparum gametocytes were noted on the thinblood film, compatible with 0.1% parasitemia. Blood cultureswere performed prior to the administration of antibiotics.

To rule out an intracranial lesion as the cause of heracute confusional state, she was transferred by ambulance toa nearby hospital with a radiologist on-site; no abnormalitieswere noted on the computed tomography scan. The patientwas transferred back to the initial hospital and was seen bythe internal medicine service at 1:30 am on February 5.Treatment for falciparum malaria with intravenous quinineand doxycycline was begun, and cefotaxime also was addedfor the possibility of bacterial sepsis. The patient’s level ofconsciousness diminished, and she was transferred to theintensive care unit. The following morning, 13 hours afterpresentation to the emergency department, she was assessedby a specialist in tropical medicine whose differential diagno-sis included meningococcemia, bacterial sepsis, denguefever, leptospirosis, rickettsial disease, viral encephalitis, andVHF. Congo–Crimean hemorrhagic fever, yellow fever, Lassafever, Ebola hemorrhagic fever, and Marburg virus hemor-rhagic fever were all considered possibilities. Given the lowlevel of parasitemia, malaria was considered an unlikelyexplanation for this acute presentation. Ribavirin, which hasactivity against Lassa fever and Congo–Crimean hemorrhag-ic fever virus, was added to her treatment regimen.

IMPLEMENTATION OF THE CANADIANCONTINGENCY PLAN

Immediate ActionsThe Canadian contingency plan specifies that if a diag-

nosis of VHF is suspected in a hospitalized patient, it is essen-tial that the institution’s infection control unit be notifiedimmediately. On suspicion of possible VHF in this patient, thehospital’s infection control service was contacted immediate-ly. In accordance with the recommendations, barrier precau-tions, including fluid-resistant gown and glove use for indi-viduals entering the room, were implemented. Fluid-resistantgowns and fluid-resistant masks that filtered 0.03 µm as wellas negative air flow were used. Although shoe covers are not

specifically recommended in the plan, these also were usedbecause of the patient’s vomiting.

Traffic into the isolation room was restricted toessential visits by healthcare providers only. All equipmentin the room was dedicated to the patient with strict orders,prior to a detailed plan on management of equipment anddisposable items, for no items to leave the room. Later, aprotocol for staff was written such that all body secretions,excretions, and fluids (including stool and suction canistermaterial) were disinfected with sodium hypochlorite (5%household bleach) prior to disposal. The patient’s roomwas decontaminated with a quaternary ammonia com-pound. Disposable items were double bagged and takendirectly to an incinerator in the hospital.

Within 1 hour of notifying the infection control unit andthe local medical health officer of the possibility of VHF, amanagement team meeting was held and included infectioncontrol, infectious diseases, public health, emergency depart-ment, intensive care, and laboratory managers as well as rep-resentatives from employee health services, public affairs,risk management, and Health Canada. The main purpose ofthe meeting was to coordinate the implementation of HealthCanada’s contingency plan for VHF.7

As meeting arrangements were being made, effortswere initiated to establish whether the diagnosis was VHF.The diagnosis of VHF is confirmed by isolating the virus,by antigen detection by enzyme-linked immunosorbentassay, viral genome detection by polymerase chain reac-tion, by demonstrating IgM antibody, or by demonstratinga fourfold rise in IgG antibody in serum. Adhering to theguidelines for transportation of dangerous goods; arrange-ments to send blood, urine, and throat swabs to theNational Microbiology Laboratory in Winnipeg, Manitoba,for serology; polymerase chain reaction; and virus isolationof VHF viruses were initiated. One set of blood tubes even-tually was tested at the National Laboratory, and a secondset subsequently was forwarded to the Centers for DiseaseControl and Prevention in Atlanta, Georgia, for testing.

Contact TracingThe contingency plan defines high-risk contacts as

individuals who have had mucous membrane contact withthe patient or have had a needlestick or other penetratinginjury involving contact with the patient’s secretions, excre-tions, blood, tissues, or other body fluids. Close contactsare individuals who have had more than casual contact withthe patient. Close contacts include individuals nursing orserving the patient, skin-to-skin contact with or huggingthe patient, and handling the patient’s laboratory speci-mens before the recognition of the nature of the differentialdiagnosis. Casual contacts are individuals who have nothad close personal contact with the ill patient.

Healthcare staff and laboratory workers who mayhave been exposed to the patient’s blood or body fluidswere contacted. Three high-risk individuals, all physicians,were identified. Two were exposed to the patient’s blood(one skin and one conjunctival exposure), and the otherwas exposed to saliva. Twenty-two close contacts were

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282 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY April 2003

identified. Sixteen of these individuals were healthcareworkers who had provided direct care to the patient priorto enhanced precautions, and 6 were laboratory workerswho had worked with specimens prior to barrier precau-tions. These laboratory technologists did not use gloveswhen preparing blood samples or handling blood speci-mens. Because laboratory services were regionalized, trac-ing these laboratory workers required tracing specimenssent to 3 separate hospitals. Sixty individuals, consistingprimarily of healthcare workers, were categorized as casu-al contacts as well as individuals who may have been in theemergency department or in the intensive care unit whenthe patient was not in full precautions, but who had nodirect contact with the patient.

Both high-risk and close contacts were asked to recordtheir temperature twice daily and report any temperature of38.3°C or higher as well as any symptoms of illness. High-risk and close contacts also were asked to defer travel plansfor at least 3 weeks because the incubation period rangesfrom 2 to 21 days for transmissible VHF viruses. To evaluatecontacts who became symptomatic, two beds on a vacant iso-lated ward in the hospital were prepared for potentialpatients. A plan was formulated such that symptomatic high-risk or close contacts could call a hotline if they developedsymptoms. If at home, they would be transported directly tothe hospital by ambulance attendants using barrier precau-tions. The infectious diseases team then would evaluate con-tacts on this unit. With the use of this strategy, two individu-als who were close contacts (one hospital employee and oneambulance attendant) were evaluated. However, both haddeveloped flu-like symptoms prior to exposure to the indexpatient and therefore were cleared.

Laboratory IssuesThe Canadian contingency plan describes the proce-

dure for procurement of laboratory specimens. This planincludes limiting testing to essential specimens, usingexperienced technologists with adherence to the Class IIbiosafety cabinet following biosafety level 3 practices (ie,protective clothing, use of gloves, and centrifugation inclosed containers using aerosol-proof safety heads), avoid-ing the use of glass containers, disposing of sharps appro-priately, and adhering strictly to universal precautionswhen blood samples are collected. To implement the rec-ommendations, prior to specimens being obtained, a labo-ratory manager was notified to ensure the appropriatearrangements for processing the specimens were made.After specimens were double bagged and then the bagswere sponged with disinfectant, specimens were takendirectly to the laboratory by nursing staff.

Automated hematology analyzers that had been usedfor the patient’s specimens were decontaminated withsodium hypochlorite. However, the manufacturers of theautomated biochemistry analyzer could not ensure thatdecontamination with sodium hypochlorite was safe for theequipment. Therefore, the biochemistry analyzer was dedi-cated to the patient’s specimens until a diagnosis of VHF wasruled out. An older analyzer was used for basic electrolyte

testing for other hospital patients, and specimens for morecomplex biochemistry testing were diverted to another hos-pital site.

Internal CommunicationAlthough the contingency plan offers no specific rec-

ommendations for internal communications, this was animportant and time-consuming aspect of caring for apatient with suspected VHF. Internal communication tohospital staff included establishing a hotline, open forums,and e-mail bulletins. Patients were provided updates by bul-letins posted to their food trays. Calls were made to nearbyhospitals, and broadcast faxes were sent to communityphysicians. Questions at open forums focused around therisk to workers and their families, as well as on why staffwho had been contacts could continue to work. Generalthemes that emerged were timing of notification (eg, somestaff were dissatisfied that laboratory staff had not beennotified sooner), safety to housekeeping staff (generally,individuals who were at the lowest risk had the highest per-ceived risk), and why some staff had been informedthrough the media. Some staff had difficulty understandingwhy high-risk or close contacts were still allowed to work.In fact, some contacts were being urged by their fellowworkers not to work. Although most staff coped reasonablywell, two staff members were significantly distressed andrequired counseling.

Media BriefingsIt was decided by the hospital and public health pub-

lic relations staff that a local news conference would beappropriate to keep local media informed. Media interest inthis case soon became intense. Precedence for interviewsand television or radio shows was given to local media so asto inform local residents and reassure them that the gener-al public was not at risk. Major national and internationalnews networks picked up the story from local news media,and in some cases, they used their own crews. Security hadto ensure that press were not entering patient care areasand the hospital boardroom, which was set up as the con-trol center where the management team met. Effective andefficient dissemination of information to the media wasaccomplished by daily news conferences that had the effectof decreasing individual requests for interviews from newsagencies. There was an additional benefit of havingspokespersons from all major involved agencies present atthe news conferences, which enabled questions to beanswered by the most appropriate individual.

Remaining Hospital CourseOn the third day of hospitalization, serology and

polymerase chain reaction were confirmed to be negativefor Ebola and Marburg virus. The patient was persistentlyfebrile and nauseated. She was treated empirically with cef-triaxone and ribavirin. On the fourth hospital day, thepatient developed adult respiratory distress syndrome andrequired intubation and ventilation. Pancreatitis was docu-mented by ultrasound.

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Vol. 24 No. 4 IMPLEMENTATION OF CONTINGENCY PLAN FOR SUSPECTED VHF 283

Given the deterioration in the clinical status of the indexpatient, a procedural plan was made for the possibility of herdeath. Arrangements for consent were made should an autop-sy be needed. However, local pathologists said they wouldrefuse to perform the autopsy based on their perceptions thatthe facilities were not suitably equipped for such a case.Arrangements therefore were made with another tertiary-care facility should the need for an autopsy arise. On the fifthday of the patient’s hospitalization, serology and polymerasechain reaction for other possible VHF were negative, and thedecision was made to step-down from the contingency plan.During the next 2 weeks, the patient gradually improved withsupportive therapy. No etiologic agent was detected despiteextensive testing. Two weeks after admission, the patient wasdischarged from the hospital in good health. No final diagno-sis was made.

DISCUSSION

This case represents the first implementation of theCanadian contingency plan for suspected VHF. Our experi-ence suggests the plan can be implemented in a tertiary-carehospital. However, specific issues that do not form part of theplan need to be anticipated. One of these issues is maintain-ing a high index for suspicion about the possibility for VHF inthe differential diagnosis. Although the initial working diag-nosis of malaria by physicians who were not specialists intropical medicine was reasonable, having included VHF inthe differential diagnosis may have led to earlier implemen-tation of the contingency plan. This would have reduced thepotential exposures to contacts and would have lessened theburden associated with tracing contacts. Difficulties in trac-ing contacts also can be anticipated. This may be especiallydifficult if the patient has been evaluated in various settings orif specimens from the patient have been sent to different lab-oratories, both of which occurred with our patient. Althoughthis article did not deal with tracing of nonhospital contacts inwhom exposure may have occurred prior to admission, suchcontact-tracing activities proved to be formidable publichealth tasks that involved multiple jurisdictions from local tointernational venues.

It is prudent for healthcare facilities to review the poli-cies and procedures they have in place for rapidly identifyingand communicating with staff. In our case, this task was leftto various managers of the clinical programs. Our tracing ofcontacts led to the discovery of potentially hazardous prac-tices in the laboratory, such as the preparation of blood sam-

ples without gloves. Communication to staff is another impor-tant area. The open forums allowed for direct feedback tostaff about their concerns and offered an important opportu-nity to educate staff about transmission of VHF and actualrisk. Dealing with the media is another challenge. Theapproach in this case was to attempt to protect the confiden-tiality of the patient at all times but at the same time give theinformation needed to assure the general public they werenot at risk. A high interest by the media should be anticipat-ed, as was demonstrated in this case.

Given that the causative agents of VHF are classified ascategory A bioweapon agents, the lessons learned in thiscase are of particular relevance. A high index of suspicion forbioterrorism must be maintained for cases of VHF in patientswith no known risk factors.9 The infection control principlesand approach described here apply to VHF cases that are dueto bioterrorism. Empiric use of ribavirin is recommended, atleast prior to identification of the causative agent of VHF.Intravenous ribavirin is recommended in a contained situa-tion. However, in the event the number of individuals requir-ing antiviral therapy is sufficiently high that delivery of intra-venous ribavirin is no longer possible, then oral ribavirin isrecommended.9

This case demonstrated that contingency plans for VHFcan be implemented in an efficient and feasible manner.Contact tracing, laboratory issues, internal communication,and media interest can be anticipated to be the key challenges.

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