Hazard Group 4, Viral Haemorrhagic Fevers Policy

DOCUMENT CONTROL:

Version: 1

Ratified by: Quality and Safety Sub Committee

Date ratified: 3 April 2017

Name of originator/author: Senior Clinical Nurse Specialist - Infection Prevention and Control

Name of responsible committee/individual:

Infection Prevention & Control Committee/Clinical Quality Group

Date issued: 13 April 2017

Review date: March 2020

Target Audience All staff

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SECTION

CONTENTS

PAGE NO.

1. INTRODUCTION 3

2. PURPOSE 3

2.1 Definitions/Explanation of Terms Used 3

3. SCOPE 4

4.

4.1

4.2

4.3

4.4

4.5

4.6

4.7

4.8

4.9

RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES

Board of Directors

Chief Executive

Director of Infection Prevention and Control

Infection Prevention and Control Committee

Infection Control Doctors/Consultant Microbiologist

Infection Prevention and Control Clinical Nurse Specialists (IPCCNS)

Consultant Medical Staff/Medical Staff

Modern Matrons/Service Managers

Staff

4

4

4

4

4

5

5

6

6

6

5.

5.1

PROCEDURE/IMPLEMENTATION

Risk Assessment

6

6

5.2

5.3

VHF Unlikely

Low Possibility VHF and High Possibility VHF

7

8

6. TRAINING IMPLICATIONS 10

7. MONITORING ARRANGEMENTS 10

8. EQUALITY IMPACT ASSESSMENT SCREENING 11

9. LINKS TO ANY ASSOCIATED DOCUMENTS 11

10. REFERENCES 12

11. APPENDICES 12

Appendix 1 – Group Hazard Group 4 Viral Haemorrhagic Fever viruses

13

Appendix 2 – Viral Haemorrhagic Fever Risk Assessment 14

Appendix 3 – Action Card for Reception/Front Facing Staff 15

Appendix 4 – Staff Contact Details 16

Appendix 5 – Contact Log 17

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1. INTRODUCTION Viral Haemorrhagic Fevers (VHFs) are severe, life-threatening viral diseases that have been reported in parts of Africa, South America, the Middle East and Eastern Europe. VHFs are of particular public health importance because they can spread within a hospital setting; they have a high case fatality rate; they are difficult to rapidly recognise and detect; and there is no effective treatment. Environmental conditions in the UK do not support the natural reservoirs or vectors of any of the haemorrhagic fever viruses, and all recorded cases of VHF in the UK have been acquired abroad, with the exception of one laboratory worker who sustained a needle-stick injury. Evidence from outbreaks strongly indicates that the main routes of transmission of VHF infection are direct contact (through broken skin or mucous membranes) with blood or body fluids, and indirect contact with environments contaminated with splashes or droplets of blood or body fluids. Experts agree that there is no circumstantial or epidemiological evidence of airborne transmission risk from VHF patients. In the UK, only persons who have; (i) travelled to an area where VHFs occur; and/or (ii) been exposed to a patient or animal infected with VHF (including their blood, body fluids or tissues); or (iii) worked in a laboratory with the infectious agents of VHFs; are at risk of infection from VHFs.

This policy is directed at the Advisory Committee on Dangerous Pathogens’ (ACDP) Group Hazard Group 4 Viral Haemorrhagic Fever viruses (Appendix 1).

2. PURPOSE

The purpose of this policy is to provide a guide to the assessment of VHF cases and the associated actions. It aims to provide efficient and timely management for patients, while preventing healthcare workers acquiring or exposing vulnerable patients to the infection. The policy content is based on sound infection prevention and control (IPC) principles and national guidance.

2.1 DEFINITIONS/EXPLANATIONS OF TERMS USED

Aspartate transaminase – an enzyme found in high levels in the liver, heart and muscles. Mucous membrane - a membrane that lines various cavities in the body including the mouth, nose, eyelids, trachea (windpipe) and lungs, stomach and intestines, and the ureters, urethra, and urinary bladder. It consists of one or more layers of epithelial cells overlying a layer of loose connective tissue. Platelet - a small colourless disc-shaped cell fragment without a nucleus, found in large numbers in blood and involved in clotting.

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3. SCOPE This policy applies to all staff having contact with patients under the care of the Trust, whether in a direct or indirect patient care role regardless of the care environment. Adherence to this policy is the responsibility of all staff employed by the Trust, including agency, locum and bank staff contracted by the Trust.

This policy should be read in conjunction with other IPC policies, particularly Hand Hygiene, Standard Infection Prevention and Control Precautions, Blood and Body Fluid Spillages, Isolation, Waste Management, Decontamination, Cleaning Systems and Processes for the Environment, Patient Equipment and Medical Devices and the Collection/Handling and Transportation of Pathology Specimens policies.

This policy should be considered and included in services that are contracted and commissioned by the Trust.

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES

4.1 Board of Directors

The Board of Directors are responsible for having policies and procedures in place to support best practice, effective management, service delivery, management of associated risks and meet national and local legislation and/or requirements.

4.2 Chief Executive

The Chief Executive (CE) is responsible for establishing and maintaining IPC arrangements across the organisation, but delegates the responsibilities to the Director for Infection Prevention and Control (DIPC).

4.3 Director for Infection Prevention and Control (DIPC)

The Director of Nursing and Quality is the DIPC. The role of the DIPC is to act on legislation, national policies and guidance to ensure effective policies are in place and audited. The DIPC directly reports to the CE and the Board:

Any outbreaks of infection

The organisations performance in relation to Healthcare Associated Infection’s (HCAI), providing regular reports including an annual report and an annual IPC programme

All incidents requiring a post infection review (PIR) 4.4 Infection Prevention and Control Committee

The main duties of the Infection Prevention & Control Committee (IPCC) are:

To oversee compliance with national standards/targets in relation to the IPC of HCAIs, including the Health and Social Care Act 2008, NHS

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Litigation Authority (NHSLA) and the Care Quality Commission (CQC) Fundamental Standards

To oversee key IPC issues in regards to:

- Policy development and review

- Audit

- Education & training

- Communication with staff patients and the public

- Monitoring of IPC incidents

- Review of PIR reports, identify lessons learnt, develop and monitor

action plans

- Agreeing the annual IPC report and work programme prior to its

submission to Clinical Governance Group

To inform the Clinical Governance Group of clinical risk issues relating to the Trust

To monitor compliance for IPC training

To oversee the Trust’s compliance with the Care Quality Commission (CQC) Fundamental Standards

4.5 Infection Control Doctors/Consultant Microbiologists

Medical microbiologists hosted within the provider acute Trusts are to:

Be available for 24 hour access, arrangements made through service agreements

Provide expert microbiology advice for the management and treatment of micro-organisms

Advise on antibiotic policy/prescribing and challenge inappropriate practices

Contribute to the PIR process

Support and provide education to all grades and all disciplines as appropriate

4.6 Infection Prevention & Control Clinical Nurse Specialists (IPCCNS)

The IPCCNS role is to:

Provide expert professional advice and education on the prevention and control of infection to other professionals, multi-disciplinary groups, patients and carers

Report findings to the DIPC and the IPCC

Lead in the investigation of identified cases of infection/alert organisms and conditions

Advise on control measures, delegating responsibility to Trust staff as appropriate

Report any breaches in policy compliance through the IR1 system

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4.7 Consultant Medical Staff/Medical Staff

Consultant medical staff are responsible for the supervision of junior medical staff and all medical staff must:

Ensure compliance with IPC policies

Liaise with the Consultant Microbiologist for advice when required

Contribute to and participate in PIR reports, including attendance at relevant meetings

Complete relevant actions required from reports 4.8 Modern Matrons/Service Managers

All Service Managers and Modern Matrons are responsible for:

Membership at the IPCC

On-going compliance with this policy within their clinical areas and reporting non-compliance to the DIPC

Reporting all matters relating to IPC to the DIPC

Facilitating feedback of information related to surveillance data and identified cases of infection/alert organisms and conditions

Reporting confirmed cases of HCAI through the Trust’s IR1 system

Ensuring that situation reports are completed to deadline as requested.

4.9 Staff

All staff must comply with this policy and related guidance. 5. PROCEDURE/IMPLEMENTATION

5.1 Risk Assessment

In the UK, only persons who have; (i) travelled to an area where VHFs occur; and/or (ii) been exposed to a patient or animal infected with VHF (including their blood, body fluids or tissues); or (iii) worked in a laboratory with the infectious agents of VHFs; are at risk of infection from VHFs. For the latest updates on countries affected please use the links below:

https://www.gov.uk/guidance/viral-haemorrhagic-fevers-origins-reservoirs-transmission-and-guidelines#history http://www.promedmail.org/

For any patient who has had a fever (≥37.5°C) or history of fever in the previous 24 hours and a travel history or epidemiological exposure within 21 days, a risk assessment (Appendix 2) must be undertaken. This is a legal obligation and will establish the patient’s VHF risk category, which determines the subsequent management of the patient and the level of protection for staff.

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If a patient telephones RDaSH services for advice, inform them to telephone their General Practitioner (GP) or the Emergency Services. An action card (Appendix 3) has been produced for reception/front facing staff. The risk to staff may change over time, depending on the symptoms of the patient, diagnostic tests results and / or information from other sources. Patients with confirmed VHF can deteriorate rapidly.

The risk assessment (Appendix 2) will assist in categorising patients as one of the following:

VHF unlikely

Low possibility of VHF

High possibility of VHF

5.2 VHF Unlikely

Patients with a fever ≥37.5C are highly unlikely to have a VHF infection if:

They have not travelled to endemic areas before the onset of illness

They have travelled to endemic areas or had contact with a known or suspected source of VHF, but in whom the onset of illness occurred > 21 days after their last contact with this source

They have not become unwell within 21 days of coming in contact with the blood, body fluid or caring a live or dead individual or animal known or strongly suspected to have a VHF

If their malaria screen in the UK is negative and they are apyrexial after more than 24 hours

If their malaria screen in the UK is positive and they are responding to anti-malaria appropriately

If they have an alternative diagnosis confirmed and are responding appropriately

In community settings clinicians will need to direct the patient to their GP for further clinical review.

In inpatient settings a medical review will be required. Clinicians will need to monitor the patient and the risk of VHF should be reassessed if a patient with a relevant history of adequate exposure fails to improve and develops one or more of the following symptoms or complications:

Bloody diarrhoea

Nose bleed

Increasing oxygen requirement in absence of other diagnosis

Clinical shock

Other indicators include:

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Sudden fall in platelets count

Sudden rise in aspartate transaminase (AST)

5.3 Low Possibility VHF and High Possibility VHF

In the event of a patient being categorised as low possibility or high possibility of VHF the clinician must immediately:

Advise the patient of the need for isolation and implement this. No person is to make further physical contact with the patient

Advise the patient that admission/transfer to hospital will be required

Inform the senior clinician/line manager (or out of hours person providing senior cover)

Complete IR1 form and update clinical records On notification from the clinician the Senior Clinician/Line Manager must:

Inform Public Health England (PHE) on relevant number below. It will automatically re-direct staff out of hours:

Doncaster and Rotherham localities - 0114 321 1177 North/North East Lincolnshire localities - 01904 687100

PHE will:

Notify the relevant Local Authority Department of Public Health

Lead and provide advice on post transfer arrangements in regards to cordoning off the premises, environmental cleaning, waste disposal, contact tracing etc.

Advise whether staff that have been in contact with the patient can continue to work

The senior Clinician/Line Manager must:

Arrange for transfer to secondary care by telephoning the ambulance service on (9)999. Ensure the ambulance service is fully aware of the risk assessment outcome so that they can ensure appropriate transfer arrangements are in place

Alert the hospital where the patient is to be admitted

In the patient’s own home setting inform the police service that a cordon of the premises will be required post patient transfer. Advise the police service to liaise with PHE

Advise staff that following patient transfer from all other settings they must cordon off all areas (including toilet facilities) occupied by patient and must advise people not to enter

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Inform staff that they must not clean the areas the patient has occupied or remove waste/linen/equipment/furniture etc. until advised by PHE on the processes required

Commence a list of staff who have had contact with the patient during the incident (Appendix 4)

Commence a log of who has been contacted, what has been reported and when it was reported (Appendix 5)

The situation must be escalated, as a priority, through the most appropriate channel to:

The Care Group Director, via TRH switchboard for the care group in which the incident occurred, or the on-call manager out of hours

Associate Nurse Director (AND), Associate Medical Director (AMD) and Head of Service (Doncaster Care Groups) for the care group in which the incident occurred, via Tickhill Road Hospital (TRH) Switchboard on 01302 796000, or the on-call manager out of hours

The Care Group Director/AND/AMD will make the decision in regards to who will take responsibility for leading on the situation and who will inform the following people/services:

The Care Group Service Manager

The Director for Infection Prevention & Control/Director of Nursing & Quality via TRH Switchboard 01302 796000

The Consultant Microbiologist for the care group the patient is in: Doncaster and North/North East Lincolnshire areas contact Doncaster Royal Infirmary on 01302 366666 Rotherham area contact Rotherham Hospital on 01709 820000, bleep 221

The Infection Prevention and Control Team on 01302 796237

The Accountable Emergency Officer (Director of Children’s & Community Services) on 01302 796399

The Emergency Planning Officer on 01302 796532 / 07500127831

The Head of Health Safety & Security on 01302 796479

RDaSH Estates on 01302 796000. For buildings outside RDaSH control contact relevant building manager (RDaSH Estates hold details of landlords)

RDaSH Communications Team on 01302 796204

The CCG in area where the incident occurred:

o Doncaster 01302 566300 o Rotherham 01709 302000 o Bassetlaw 01777 274400 o North Lincolnshire 01652 251000 o North East Lincolnshire 0300 300 0400

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Out of hours inform:

NHS England EPRR Team: 0333 012 4267 (ask for NHS England 1st On Call)

South Yorkshire CCGs: 01709 820000 (ask for on call CCG Manager) North Lincolnshire: 07767 610008 The relevant Care Group Director/Head of Specialist Services should:

Appoint a Trust spokesperson to agree the lines to take in case of media enquiries. Response to enquiries must correspond and be agreed with PHE and NHS England Area Team

Ensure switchboard and all staff are given guidance on media handling in the event of media attention

Consider opening Incident Coordination Centre/Trust Gold Command (Boardroom 2 Woodfield House) to coordinate response to incident

Consult Major Incident Plan Action Cards

The Police may convene a Multi-Agency Strategic Coordinating Group to manage the response to the incident. The CCG may convene a Local Health Economy Tactical Coordinating Group. Trust Directors may choose to declare a critical or major incident depending on advice from CCGs, PHE and NHS England.

6. TRAINING IMPLICATIONS

There are no specific training needs in relation to this policy, but all clinical staff will need to be familiar with its contents. As a Trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through a number of a variety of means such as: Team Brief Weekly Newsletter Trust wide mail drop Trust wide email Team meetings Special meetings One to one meetings / Supervision Group supervision Posters Practice Development Days CPD sessions Local induction

7. MONITORING ARRANGEMENTS

Area for Monitoring

How Who by Reported to Frequency

Incidents of possibility, high possibility or confirmed VHF

Via IR1 reports DIPCC/Head of Nursing/Managers/ Matrons and IPC Team

Infection Prevention and Control Committee

Bi-monthly

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8. EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on this policy’s RDaSH Policy Library webpage.

8.1 Privacy, Dignity and Respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). No issues have been identified in relation to this policy.

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the Court

Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005.

9. LINKS TO ANY ASSOCIATED DOCUMENTS

http://www.rdash.nhs.uk/category/publications/policies/clinical-policies/infection-prevention-and-control/ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/534002/Management_of_VHF_A.pdf http://www.promedmail.org/ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/365845/VHF_Africa_960_640.png

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https://www.gov.uk/guidance/lassa-fever-origins-reservoirs-transmission-and-guidelines https://www.gov.uk/guidance/ebola-and-marburg-haemorrhagic-fevers-outbreaks-and-case-locations http://www.who.int/csr/disease/crimean_congoHF/Global_CCHFRisk_20080918.png?ua=1

10. REFERENCES

Department of Health (2015) Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence. Advisory Committee on Dangerous Pathogens.

11. APPENDICES

Appendix 1 – Group Hazard Group 4 Viral Haemorrhagic Fever viruses Appendix 2 – Viral Haemorrhagic Fever Risk Assessment Appendix 3 – Action Card for Reception/Front Facing Staff Appendix 4 – Staff Contact Details Appendix 5 – Contact Log

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Appendix 1

Advisory Committee on Dangerous Pathogens’ (ACDP) Group Hazard Group 4 Viral Haemorrhagic Fever viruses

ARENAVIRIDAE Old World arenaviruses Lassa Lujo New World arenaviruses Chapare Guanarito Junin Machupo Sabiá BUNYAVIRIDAE Nairoviruses Crimean Congo haemorrhagic fever FLAVIVIRIDAE Kyasanur forest disease Alkhurma haemorrhagic fever* Omsk haemorrhagic fever FILOVIRIDAE Ebola Marburg *Hazard Group 3 agent, but included in this guidance as “similar human infectious disease of high consequence”

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Appendix 2

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Appendix 3

ACTION CARD FOR RECEPTION / FRONT FACING STAFF

THINK VIRAL HAEMORRHAGIC FEVER (VHF)

If a patient attends with any of the following symptoms

Diarrhoea and or vomiting

Lethargy

Sore throat Please ask the following questions: 1. Has the patient had a temperature of over 37.5° or history of

high fever in the last 24 hours? 2. Has the patient developed symptoms within 21 days of leaving

a VHF endemic country?

An outbreak of VHF and the countries affected will be widely publicised in the media or can be checked here:

http://www.promedmail.org/

If the answer is yes to both questions:

Alert a senior clinician or manager, telling them a patient may be triggering the VHF pathway

Instruct the patient to wait until seen by a clinician

Direct the patient into a room away from other patients and staff

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Appendix 4

Staff Contacts

Name Role

Contact details

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Appendix 5

Contact Log

Contact Number Date & Time contacted

Contact Name Comments/Advice Received

PHE

Don & Roth

North/North East Lincs

0114 3211177

01904 687100

Ambulance Service

Police Service (in patients own home)

(9) 999

Associate Directors of Nursing for the relevant Care Group

Via TRH Switchboard

01302 796000

Associate Medical Director for the relevant Care Group

Via TRH Switchboard

01302 796000

Care Group Director /Head of Specialist Services in Doncaster

Via TRH Switchboard

01302 796000

The Director for Infection Control

Via TRH Switchboard

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Contact Number Date & Time contacted

Contact Name Comments/Advice Received

(Director of Nursing & Quality)

01302 790000

Consultant Microbiologist:

Doncaster, and North/North East Lincolnshire areas

Rotherham area contact Rotherham Hospital

01302 366666

01709 820000, bleep 221

The Infection Prevention and Control Team

01302 796237

The Accountable Emergency Officer (Director of Children’s & Community Services)

01302 796399

The Emergency Planning Officer

01302 796532 / 07500 127831

The Head of Health Safety & Security

01302 796479

RDaSH Estates

Estates hold details of landlords for non-trust owned properties)

Via TRH Switchboard

01302 796000

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Contact Number Date & Time contacted

Contact Name Comments/Advice Received

The Communications Team

01302 796204

The CCG

Doncaster

Rotherham

Bassetlaw

North Lincolnshire

North East Lincolnshire

Out of Hours South Yorkshire CCGs: ask for on call CCG Manager

North Lincolnshire

01302 566300

01709 302000

01777 274400

01652 251000

0300 300 0400

01709 820000

07767 610008

NHS England EPRR Team: (ask for NHS England 1st On Call)

0333 012 4267